Neonatal Sleep Predicts Attention Orienting and Distractibility

OBJECTIVE

Children with sleep disorders tend to experience attention problems, yet little is known about the relationship between sleep and attention in early development. This prospective follow-up study investigated the longitudinal relationships between neonatal sleep, attention, and distraction in infants born preterm.

METHOD

We used actigraphy and sleep-wake diaries in the neonatal intensive care unit (NICU, N = 65), attention orienting in a visual-recognition-memory task (VRM) at age 4 months, and structured observation of attention and distractibility at age 18 months.

RESULTS

Infants with poorer neonatal sleep (n = 31) exhibited longer first gaze durations in the VRM at 4 months and longer distraction episodes at 18 months relative to neonatal controls who slept well (p < .01). Hierarchical regression models support relations between neonatal sleep and gaze behavior at 4 months and distractibility at 18 months; moreover, alterations in orienting attention at 4 months predicted the likelihood of being distracted during the second year of life.

CONCLUSION

Findings underscore the importance of early sleep-wake and attention regulation in the development of distraction in infants born preterm.

The role of the father in child sleep disturbance: child, parent, and parent-child relationship

The majority of studies on child sleep problems focus primarily on mothers, neglecting paternal influences. Guided by the transactional framework, we explored how child temperament, paternal and maternal stress, and the parent-child interactions differ between families having children with sleep disturbances and a selected comparison group. The role of paternal involvement in child caregiving as a moderator of these differences was assessed. The sample consisted of 51 children (1-3 years old) and their mothers and fathers. Data were collected during home visits, when mothers and fathers completed questionnaires and were interviewed. In addition, mother-child and father-child interactions were videotaped. Results indicate that compared to the comparison group, fathers rated children with sleep disturbances as fussier, both their mothers and fathers experienced higher levels of stress, and reported using more bedtime interactions that interfere with child's sleep-wake self-regulation. In addition, their fathers were less sensitive during father-child interaction and less involved in child caregiving. Finally, paternal involvement moderated the group differences seen in maternal stress, suggesting that high paternal involvement acted as a buffer to protect parents of children with sleep disturbances from experiencing parental stress. The important role of fathers in families having children with sleep disturbances is discussed.

Behavioral Sleep Problems and their Potential Impact on Developing Executive Function in Children

Bedtime resistance and night waking are common sleep problems throughout childhood, especially in the early years. These sleep problems may lead to difficulties in neurobehavioral functioning, but most research into childhood sleep problems has not emphasized the importance of the developmental context in which disruptions in neurobehavioral and daytime functioning occur. We review the development of sleep as well as executive functioning (EF) in childhood and suggest that EF may be particularly vulnerable to the effects of these common childhood sleep problems because of its prolonged course of maturation. Behavioral problems associated with common sleep problems suggest poor self-regulation in the context of sleep loss, and developing EF skills play important roles in self-regulation. A research agenda that considers a developmental approach to sleep and sleep problems in the context of childhood EF performance is outlined to promote future research in this area.

CITATION

Turnbull K; Reid GJ; Morton JB. Behavioral sleep problems and their potential impact on developing executive function in children. SLEEP 2013;36(7):1077-1084.

Causes and correlates of frequent night awakenings in early childhood

Night awakenings are a normative part of early development. In the first year, night awakenings are associated with birth order, feeding route, sleep aid use, sleep location, infant temperament and development, infant-parent attachment, family socioeconomics, and cultural norms. In the second year, additional factors build on these foundational features, including parenting practices and object attachment. As children grow, contextual factors like preschool entry or changes in family member status may influence the continuation or exacerbation of awakenings. Future research should consider the multitude of factors that influence not only awakenings but also parental perceptions, family dynamics, and cultural norms.

Infant well-being following neonatal cardiac surgery

AIMS AND OBJECTIVES

To investigate infant well-being as measured by feeding and sleeping and parental support following discharge from the NICU in infants following major cardiac surgery.

BACKGROUND

Infant feeding and sleeping have been identified as two of the most important concerns reported by parents. These concerns have been reported anecdotally for infants who have undergone cardiac surgery in the neonatal period.

DESIGN

A prospective study using questionnaires and phone interviews followed a cohort of parents of neonates who underwent surgery in the neonatal period for congenital heart disease.

METHODS

The study was conducted using validated questionnaires and phone interviews with a semi-structured questionnaire. The questionnaires were administered prior to discharge from the NICU and interviews took place following discharge on five occasions within nine months.

RESULTS

Fifty six infants and mothers were followed for nine months following discharge from NICU. Sixty-eight per cent were breastfeeding on discharge however the rates decline over time in line with healthy infants. Mothers were not bothered by their infant's sleep patterns which were consistent with those of healthy infants at six months. There were 37 episodes of re-hospitalisation and the average time of further surgery was five months following discharge from their initial period of hospitalisation.

CONCLUSION

The issues from this pilot study warrant further investigation. Factors such as multiple hospitalisations, parent education and support may vary within contexts and need to be studied to ensure optimal supports are identified for this high risk population.

RELEVANCE TO CLINICAL PRACTICE

This study identified several issues that can improve care provided to these infants and their parents. Support following discharge could include: lactation consultant to provide follow-up calls to identify concerns with breastfeeding, lactation course for paediatric nurses providing follow-up and education for Early Childhood Clinics on Congenital Heart Disease.

Infant sleep and paternal involvement in infant caregiving during the first 6 months of life

OBJECTIVES

The goals of this study were to assess: (a) the involvement of fathers and mothers in overall and nighttime infant caregiving; (b) the links between paternal involvement in infant care and infant sleep patterns during the first 6 months.

METHODS

Fifty-six couples recruited during their first pregnancy, participated in the study. After delivery (1 and 6 months), both parents completed a questionnaire assessing the involvement of fathers relative to mothers in infant caregiving. Infant sleep was assessed using actigraphy and sleep diaries.

RESULTS

Mothers were significantly more involved than fathers in daytime and nighttime caregiving. A higher involvement of fathers in overall infant care predicted and was associated with fewer infant night-wakings and with shorter total sleep time after controlling for breastfeeding.

CONCLUSIONS

The findings highlight the importance of including fathers in developmental sleep research. Future studies should explore mechanisms underlying the relations between paternal involvement and infant sleep.

Maternal sleep-related cognitions and infant sleep: a longitudinal study from pregnancy through the 1st year

Infant sleep is a major source of concern for many parents. The aims of this longitudinal study were to assess: (a) the development of sleep patterns among infants, (b) the development of maternal cognitions regarding infant sleep, and (c) the relations between these domains during the 1st year of life. Eighty-five mothers were recruited during pregnancy and completed a questionnaire aimed at assessing maternal sleep-related cognitions. After delivery (at 1, 6, and 12 months) sleep was assessed using actigraphy and sleep logs, and maternal cognitions were reassessed. The findings demonstrated significant predictive and concomitant links between maternal cognitions and infant sleep. Maternal soothing behaviors mediated the relations between these domains.

Opportunities for the primary prevention of obesity during infancy

Many parents, grandparents, and clinicians have associated a baby’s ability to eat and gain weight as a sign of good health, and clinicians typically only call significant attention to infant growth if a baby is failing to thrive or showing severe excesses in growth. Recent evidence, however, has suggested that pediatric healthcare providers should pay closer attention to growth patterns during infancy. Both higher weight and upward crossing of major percentile lines on the weight-for-age growth chart during infancy have long term health consequences, and are associated with overweight and obesity later in life. Clinicians should utilize the numerous available opportunities to discuss healthy growth and growth charts during health maintenance visits in the first two years after birth. Further, providers should instruct parents on strategies to promote healthy behaviors that can have long lasting obesity preventive effects.

Sleep and sleep ecology in the first 3 years: a web-based study

This study was designed to provide data on sleep patterns during the first 3 years, based on a large US-Canada Internet sample, to assess the prevalence of parental interventions and related factors of infant sleep ecology and to evaluate the links between sleep ecology and sleep. Five thousand six parents completed a web-based online questionnaire about their children, aged from birth to 36 months. The questionnaire included items pertaining to sleep patterns, sleep environment, sleep-related parental interventions, sleep position, and demographic information. The results reflected clear sleep-related developmental changes including a decrease in daytime sleep and total sleep time, as well as consolidation of sleep during the night, which was manifested in a decrease in night wakings and nocturnal wakefulness. Sleep ecology and parental behaviors significantly explained a portion of the variance in the child's sleep patterns. Parental interventions that encourage independence and self-soothing were associated with extended and more consolidated sleep, especially in comparison to more active interactions that were associated with shorter and more fragmented sleep. These findings provide parents and professionals reference data for assessing sleep in young children. Furthermore, the results provide information on specific ecological factors that are associated with increased risk for sleep problems.

Sleep disturbances in visually impaired toddlers

OBJECTIVE

This study set out to describe sleep patterns in visually impaired (VI) children during the first 40 months of life compared to typically developing children. We also evaluated the influence of age, sex and the presence of other disabilities on sleep patterns.

PATIENTS AND METHODS

A sleep questionnaire was administered to 154 parents of 10- to 39-month-old children: 36 with visual impairment without associated disability; 68 with visual impairment and associated disabilities (cortical visual impairment); and 50 healthy controls. The groups were balanced by age and gender. The questionnaire was developed at the C. Mondino Institute of Neurology in Pavia, Italy with the aim of investigating sleep patterns and medical history.

RESULTS

Within the VI sample, sleep behaviour was not related to the presence of associated disabilities. Visually impaired children had higher sleep disturbance scores than healthy controls using the Richman Criteria. VI children took longer to fall asleep, and their nocturnal awakenings were longer, more frequent per night, and affected more nights per week compared to the controls.

CONCLUSIONS

The results of this study show that the sleep of VI children is characterized by increased difficulty in falling asleep and in sleeping through the night, compared with that of their healthy peers. These findings confirm those of other important studies on sleep in VI children and underline the importance of evaluating and taking into account sleep-wake cycle in the care of the VI child.

Sleep problems in children with autism spectrum disorders, developmental delays, and typical development: a population-based study

This study compared parent-reported sleep characteristics in 2- to 5-year-old children with autism spectrum disorders (ASD) to children with other developmental delays (DD) and typical development (TD). We included 529 children (303 ASD [167 males], 63 DD [46 males], and 163 TD [134 males]) enrolled in the CHARGE study, an ongoing population-based case-control study. The mean age of participants was 3.6 years (standard deviation, 0.8 years). ASD diagnosis was confirmed with Autism Diagnostic Interview-Revised (ADI-R) and Autism Diagnostic Observation Schedules (ADOS). Cognitive and adaptive functioning was assessed using Mullen Scales of Early Learning (MSEL) and Vineland Adaptive Behavior Scales (VABS), respectively. Demographic, medical and sleep history information were ascertained from California birth records, telephone interview, medical assessments at clinic visit, and parent-administered questionnaires. Fifty-three percent of children with ASD had at least one frequent sleep problem, followed by 46% of children with DD, and 32% of the TD group (P < 0.0001). Exploratory factor analyses of sleep history data yielded two factors: sleep onset problems and night waking. Children with ASD had marginally higher sleep onset factor scores and significantly higher night waking factor scores compared with the TD group. Factor scores for children with DD were intermediate between the ASD and TD groups. Cognitive or adaptive development did not predict severity of sleep problems in the ASD group.

Maternal separation anxiety as a regulator of infants' sleep

BACKGROUND

The regulation of infants' sleep is determined not only by biological factors but by relational aspects too. This study focused on maternal separation anxiety and examined its association with sleep-wake regulation at 10 months of age.

METHOD

In a community sample comprising 52 infants and their mothers, sleep was measured objectively with an activity monitor, as well as through questionnaires. The mothers reported on their own separation anxiety and on the child's perceived distress.

RESULTS

The main finding was that maternal separation anxiety was linked to settling to sleep routines and to night-waking. The contribution of the mothers' own separation anxiety to their infants' night-waking remained significant after controlling for the child's fussiness.

CONCLUSIONS

Consistent with the transactional perspective, the current research documented an interplay between maternal separation anxiety and aspects of the child's sleep-wake transitions.

Versión española del Pediatric Sleep Questionnaire . Un instrumento útil en la investigación de los trastornos del sueño en la infancia. Análisis de su fiabilidad

INTRODUCTION

Sleep questionnaires are useful tools both for screening patients who require medical tests and for epidemiologic research. The Pediatric Sleep Questionnaire (PSQ) has two versions: a shorter one, which has been validated for sleep-related breathing disorders, and an extended version, which deals with a wider range of sleep disturbances.

MATERIAL AND METHODS

The PSQ was translated into Spanish and its reliability was determined by means of test-retest and internal consistency methods among a random sample of 99 patients.

RESULTS

Ninety-one percent of the questions showed good concordance, following the criteria established in the test- retest method. Internal consistency was good in parts A (nighttime and sleep behavior) and C (items for inattention and hyperactivity) of the questionnaire but was weak in part B (daytime behavior and other possible problems). Therefore, the reliability of the questionnaire can be considered to be adequate except for the internal consistency of part B.

CONCLUSIONS

The Spanish version of the PSQ is a suitable tool both for screening patients who require medical tests and for epidemiological research.

Locomotion and nightwaking

OBJECTIVE

In this study we addressed the association between two major achievements of infancy: independent locomotion and 'sleeping through the night'.

METHODS

Mothers of 107 healthy infants aged between five and eight months completed a sleep questionnaire and a motor checklist.

RESULTS AND CONCLUSIONS

Infants who were already crawling had more bedtime difficulties and nightwaking than did pre-crawlers. Among 7- and 8-month-old infants, locomotion predicted 17% of nightwaking variance, after controlling for age and gender. In discussing the developmental implications of locomotion we suggest that crawling may not only 'broaden the mind' but also 'cost' sleep. More studies, across time, on how motor development and sleep-wake regulation interrelate are recommended.

Infant sleep at 10 months of age as a window to cognitive development

This study examined the association between sleep-wake patterns and achievements on the Bayley Scales of Infant Development, in a low-risk sample of 10-month-olds. The sleep of 50 infants was recorded at home by means of a small activity monitor (actigraph). More motor activity in sleep and more fragmented sleep pattern were moderately associated with lower mental developmental index (MDI) scores. The psychomotor developmental index (PDI) was not associated with the sleep characteristics. The finding that at the end of the first year, sleep quality accounted for a significant, albeit small, percentage of the cognitive achievement variance is in line with a model that links sleep-wake states and behavior regulation during arousal.

Children's sleep: an interplay between culture and biology

Pediatricians provide a major source of knowledge for parents about children's behavior and development, although their advice is largely based on their own cultural values and beliefs in interaction with their personal and clinical experience. This review presents cross-cultural aspects of children's sleep behavior in industrialized and complex modern societies and provides a basis for understanding dimensions and mechanisms of cultural differences. We submit that it is the interaction between culture and biology that establishes behavioral and developmental norms and expectations regarding normal and problematic children's sleep. Pediatricians need to recognize the cultural environment in which children live and be knowledgeable about how cultural beliefs and values of both families and physicians interact with the needs and biological characteristics of individual children.

A brief screening questionnaire for infant sleep problems: validation and findings for an Internet sample

OBJECTIVE

To develop and validate (using subjective and objective methods) a brief infant sleep questionnaire (BISQ) that would be appropriate for screening in pediatric settings.

DESIGN

Two studies were performed to assess the properties of the BISQ. Study I compared BISQ measures with sleep diary measures and objective actigraphic sleep measures for clinical (N = 43) and control (N = 57) groups of infants (5-29 months of age). The second study was based on an Internet survey of 1028 respondents who completed the BISQ posted on an infant sleep web site.

RESULTS

In study I, BISQ measures were found to be correlated significantly with sleep measures derived from actigraphy and sleep diaries. BISQ measures (number of night wakings and nocturnal sleep duration) were the best predictors for distinguishing between clinical and control samples. High test-retest correlations (r >.82) were demonstrated for BISQ measures for a subsample of 26 infants. Study II provided a developmental perspective on BISQ measures. The study demonstrated that BISQ measures derived from a large Internet survey provided developmental and sleep ecology-related findings that corresponded to the existing literature findings on sleep patterns in early childhood.

CONCLUSIONS

The findings provide psychometric, clinical, and ecologic support for the use of the BISQ as a brief infant sleep screening tool for clinical and research purposes. Potential clinical cutoff scores are provided.

Attachment and sleep: a study of night waking in 12-month-old infants

Sleep regulation was examined from a mother-child relational perspective. Although the link between sleep and attachment has been previously discussed, empirical support is rather limited. This report, which is a part of a longitudinal investigation of sleep in infancy, examines the association between the child's sleep pattern and mother-infant attachment in 94 mother-infant dyads. At 12 months each dyad participated in the Strange Situation procedure; 77% were securely attached. Mothers' description of the infant's fussiness was not found to predict the attachment pattern, but was associated with the sleep habits. It was found that 55% of the secure and 60% of the ambivalent children were described as night wakers. To a sub-group of 37 infants, a sleep monitor (actigraph) was provided for two nights' recordings. The frequency of the objective awakenings was higher than what mothers reported but similar for the secure and insecure infants. The findings confirm that night waking at the end of the first year is a common developmental phenomenon. Among this group of non-risk infants, sleep characteristics were only marginally associated with the quality of the child's attachment relationship.

Classification of young children's sleep problems: a pilot study

OBJECTIVES

This study examines videotaped sleep in infancy in an attempt to predict the development of disturbed sleep during toddlerhood. In addition, a tentative classification scheme that quantifies night waking and sleep onset problems in young children is proposed.

METHOD

The sleep patterns of 33 children were assessed at two points in time. At 12 months of age (time 1), sleep was videotaped on two consecutive nights. A self-soothing/signaling index for 12-month-olds was constructed. At time 2 (mean age = 39 months), a follow-up telephone interview assessed current sleep patterns and the presence or absence of sleep problems.

RESULTS

The data suggest that the self-soothing/signaling index obtained at 12 months of age predicts night waking approximately 2 years later.

CONCLUSIONS

The preliminary classification scheme for night waking and sleep onset problems in young children warrants further study. Night waking in toddlers might be predictable from sleep behaviors at 1 year of age.

Night waking among 1-year olds: a study of maternal separation anxiety

The relationships between aspects of parenting and infants' sleep patterns were studied longitudinally with 81 mother-child pairs. Mothers' parenting orientation at 6 months was defined using the Facilitator-Regulator distinction. When the infants were 12 months old, mother and child participated in a laboratory-based developmental assessment which involved a brief separation episode. Upon reunion, mothers reported on their concerns during separation; they also described their child's sleep. It was found that high maternal separation anxiety was related to night waking. In addition, night waking was more frequent among first born babies of Facilitators compared with Regulators. How maternal separation anxiety and care-giving orientation regulate aspects of the child's sleep awaits further explanation.