Development and evaluation of 'Sleep, Baby & You'-An approach to supporting parental well-being and responsive infant caregiving

'Either something's wrong, or I'm a terrible parent': A systematic review of parent experiences of illness-related interpretations for unsettled babies

AIMS

To explore parents' experiences of unsettled babies and medical labels.

DESIGN

Qualitative systematic review, thematic synthesis and development of a conceptual model.

REVIEW METHODS

Systematic review and thematic synthesis of primary, qualitative research into parents' experiences of unsettled babies <12 months of age. 'Unsettled' was defined as perception of excessive crying with additional feature(s) such as vomiting, skin or stool problems. The Critical Appraisal Skills Programme (CASP) checklist was used to assess trustworthiness.

DATA SOURCES

Structured searches completed in CINAHL, Medline, Embase, PsychINFO and CochraneCT on 23 March 2022 and rerun on 14 April 2023.

RESULTS

Ten eligible studies were included across eight countries contributing data from 103 mothers and 24 fathers. Two analytical themes and eight descriptive themes were developed. Firstly, parents expressed fearing judgement, feeling guilty and out of control as a result of babies' unsettled symptoms and seeking strategies to construct an 'Identity as a "Good Parent"'. This desire for positive parenting identity underpinned the second analytical theme 'Searching for an explanation' which included seeking external (medical) causes for babies' unsettled behaviours.

CONCLUSION

Parents can become trapped in a cycle of 'searching for an explanation' for their baby's unsettled behaviours, experiencing considerable distress which is exacerbated by feelings of guilt and failure.

IMPACT AND IMPLICATIONS FOR PATIENT CARE

Insight gained from this review could inform interventions to support parents, reducing inaccurate medicalization. Health visiting teams supporting parents with unsettled baby behaviour could focus on supporting a positive parenting identity by managing expectations, normalizing the continuum of infant behaviours, reducing feelings of guilt or uncertainty and helping parents regain a feeling of control.

REPORTING METHOD

ENTREQ guidelines were adhered to in the reporting of this review.

PATIENT OR PUBLIC CONTRIBUTION

Parent input was crucial in the design phase; shaping the language used (e.g., 'unsettled babies') and in the analysis sense-checking findings.

Instrument development and an intervention to increase parents' self-efficacy regarding their infant's sleep

OBJECTIVE

Many Swedish parents experience that their infant has sleeping problems. Parents' self-efficacy regarding their infants' sleep may play an important role in how they perceive these problems. This pilot study aimed to develop an instrument measuring parents' self-efficacy regarding their infant's sleep and to examine if parents' self-efficacy was affected by an intervention focusing on parental education.

METHOD

Mothers and fathers, at a maternity unit in Sweden, were drawn into either an intervention (n = 46) or a control (n = 42) group. The intervention group received a home visit from a nurse who provided information about infant sleep; the importance of attachment; and advice regarding sleep, breastfeeding and bed sharing, including guidelines for safe bed sharing. Three months later, the participants answered questions on background data, breastfeeding, sleep and self-efficacy.

RESULTS

The 11-item two-factor Uppsala Parental Self-Efficacy about Infant Sleep Instrument (UPPSEISI) was constructed to measure parents' perceived self-efficacy. In adjusted analyses, being in the intervention group was associated with a higher self-efficacy (P = 0.035), as were being a mother (P = 0.003) and being satisfied with one's own sleep (P = 0.007), while parents' own sleeping problems were associated with a lower self-efficacy (P = 0.015).

CONCLUSION

Importantly, parental education may increase parents' self-efficacy regarding their infant's sleep.

Contextual considerations in infant sleep: Offering alternative interventions to families

Infant sleep problems are one of the commonly reported reasons parents seek professional help, yet what constitutes a "sleep problem" depends on the models used to explain the development of infant sleep. The current models are based on research conducted in the western context where infant solitary sleeping is the norm. Parent-child co-sleeping is the norm in many cultures around the world. We argue that the primary focus of current research on parent-child interactions as the mediating context for the development of infant sleep problems has inherently made these models and ensuing interventions less sensitive and applicable to infant sleep problems in the context of co-sleeping families. When families present for help with infant sleep difficulties, extinction based behavioral interventions or interventions focused on reducing parental presence at bedtime are commonly recommended. These recommendations may not always align with cultural values and parenting practices of all families, therefore precluding these families from getting necessary help. In attempting to provide families with choices that depart from behavioral based interventions, this paper draws on research and adapts current models to propose an alternative to conceptualize perceptions of infant sleep problems that may be sensitive to and applied across various cultural and personal contexts. We attempt to provide a rationale for interventions that are inclusive and sensitive to families where reduced parental nighttime responsiveness may not be a preferred choice.

ABM Clinical Protocol #37: Physiological Infant Care-Managing Nighttime Breastfeeding in Young Infants

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).

UK parents' help-seeking for child sleep: A qualitative investigation into parental preferences and reservations about resources

Child sleep is a common parental concern and there is an array of resources available to parents. However, an exploration of UK parents' help-seeking behaviours around child sleep is lacking. This study sought to identify the resources parents use to seek information and help for child sleep, as well as to explore what factors parents prefer about certain sources and their reservations about using other resources. Parents of 6-36 month old children residing in the United Kingdom (UK) completed an online questionnaire between October 2015 and October 2016 about their use, opinions and experiences regarding resources for child sleep. Quantitative data were descriptively analysed and thematic analysis was conducted on parents' open-ended text responses. Participants were 266 UK parents (97% mothers). Parents' ages ranged from 21 to 45 years (M = 33.49 years, SD = 4.71) and all resided in the United Kingdom (UK). General Internet searches were the most commonly reported source used by 47% of parents with a range of other informal resources also frequently consulted. Health Visitors (HVs) were the most accessed healthcare professional reportedly consulted by 38% of parents. Seven themes represented parental preferences for their resource use. Most strongly endorsed included a desire for information from other parents, particularly those with practical experience and accessing information that aligned with their parenting values. Parents preferred sources that provided support and reassurance, as well as those that afforded parents the ability to select relevant elements from a range of information. Seven themes represented parents' reservations about resources. Most strongly endorsed were concerns about reliability, being judged and challenges associated with filtering vast amounts of information. Parents reported having reservations towards sources if they had a previous negative experience with the source. Possible implications of the findings and specific suggestions about how existing and future resources could be adapted to better meet parents' needs are highlighted.

Breastfeeding and Maternal Perceptions of Infant Sleep, Settle and Cry Patterns in the First 9 Months

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.

Infant sleep as a topic in healthcare guidance of parents, prenatally and the first 6 months after birth: a scoping review

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.

An overview of reviews for preventing and treating sleep problems in infants

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.

Correlates of Canadian mothers' anger during the postpartum period: a cross-sectional survey

BACKGROUND

Although some women experience anger as a mood problem after childbirth, postpartum anger has been neglected by researchers. Mothers' and infants' poor sleep quality during the postpartum period has been associated with mothers' depressive symptoms; however, links between mothers' sleep quality and postpartum anger are unclear. This study aimed to determine proportions of women with intense anger, depressive symptoms, and comorbid intense anger and depressive symptoms, and to examine mothers' and infants' sleep quality as correlates of postpartum anger.

METHODS

This cross-sectional survey study was advertised as an examination of mothers' and babies' sleep. Women, with healthy infants between 6 and 12 months of age, were recruited using community venues. The survey contained validated measures of sleep quality for mothers and infants, and fatigue, social support, anger, depressive symptoms, and cognitions about infant sleep.

RESULTS

278 women participated in the study. Thirty-one percent of women (n = 85) reported intense anger (≥ 90th percentile on State Anger Scale) while 26% (n = 73) of mothers indicated probable depression (>12 on Edinburgh Postnatal Depression Scale). Over half of the participants rated their sleep as poor (n = 144, 51.8%). Using robust regression analysis, income (β = -0.11, p < 0.05), parity (β = 0.2, p < 0.01), depressive symptoms (β = 0.22, p < 0.01), and mothers' sleep quality (β = 0.10, p < 0.05), and anger about infant sleep (β = 0.25, p < 0.01) were significant predictors of mothers' anger.

CONCLUSIONS

Mothers' sleep quality and anger about infant sleep are associated with their state anger. Clinicians can educate families about sleep pattern changes during the perinatal time frame and assess women's mood and perceptions of their and their infants' sleep quality in the first postpartum year. They can also offer evidence-based strategies for improving parent-infant sleep. Such health promotion initiatives could reduce mothers' anger and support healthy sleep.

Re-thinking lactation-related nipple pain and damage

Nipple pain is a common reason for premature cessation of breastfeeding. Despite the benefits of breastfeeding for both infant and mother, clinical support for problems such as maternal nipple pain remains a research frontier. Maternal pharmaceutical treatments, and infant surgery and bodywork interventions are commonly recommended for lactation-related nipple pain without evidence of benefit. The pain is frequently attributed to mammary dysbiosis, candidiasis, or infant anatomic anomaly (including to diagnoses of posterior or upper lip-tie, high palate, retrognathia, or subtle cranial nerve abnormalities). Although clinical protocols universally state that improved fit and hold is the mainstay of treatment of nipple pain and wounds, the biomechanical parameters of pain-free fit and hold remain an omitted variable bias in almost all clinical breastfeeding research. This article reviews the research literature concerning aetiology, classification, prevention, and management of lactation-related nipple-areolar complex (NAC) pain and damage. Evolutionary and complex systems perspectives are applied to develop a narrative synthesis of the heterogeneous and interdisciplinary evidence elucidating nipple pain in breastfeeding women. Lactation-related nipple pain is most commonly a symptom of inflammation due to repetitive application of excessive mechanical stretching and deformational forces to nipple epidermis, dermis and stroma during milk removal. Keratinocytes lock together when mechanical forces exceed desmosome yield points, but if mechanical loads continue to increase, desmosomes may rupture, resulting in inflammation and epithelial fracture. Mechanical stretching and deformation forces may cause stromal micro-haemorrhage and inflammation. Although the environment of the skin of the nipple-areolar complex is uniquely conducive to wound healing, it is also uniquely exposed to environmental risks. The two key factors that both prevent and treat nipple pain and inflammation are, first, elimination of conflicting vectors of force during suckling or mechanical milk removal, and second, elimination of overhydration of the epithelium which risks moisture-associated skin damage. There is urgent need for evaluation of evidence-based interventions for the elimination of conflicting intra-oral vectors of force during suckling.

Re-thinking benign inflammation of the lactating breast: Classification, prevention, and management

Despite the known benefits of breastfeeding for both infant and mother, clinical support for problems such as benign inflammation of the lactating breast remain a research frontier. Breast pain associated with inflammation is a common reason for premature weaning. Multiple diagnoses are used for benign inflammatory conditions of the lactating breast which lack agreed or evidence-based aetiology, definitions, and treatment. This article is the second in a three-part series. This second review analyses the heterogeneous research literature concerning benign lactation-related breast inflammation from the perspectives of the mechanobiological model and complexity science, to re-think classification, prevention, and management of lactation-related breast inflammation. Benign lactation-related breast inflammation is a spectrum condition, either localized or generalized. Acute benign lactation-related breast inflammation includes engorgement and the commonly used but poorly defined diagnoses of blocked ducts, phlegmon, mammary candidiasis, subacute mastitis, and mastitis. End-stage (non-malignant) lactation-related breast inflammation presents as the active inflammations of abscess, fistula, and septicaemia, and the inactive condition of a galactocoele. The first preventive or management principle of breast inflammation is avoidance of excessively high intra-alveolar and intra-ductal pressures, which prevents strain and rupture of a critical mass of lactocyte tight junctions. This is achieved by frequent and flexible milk removal. The second preventive or management principle is elimination of the mechanical forces which result in high intra-alveolar pressures. This requires elimination of conflicting vectors of force upon the nipple and breast tissue during milk removal; avoidance of focussed external pressure applied to the breast, including avoidance of lump massage or vibration; and avoidance of other prolonged external pressures upon the breast. Three other key preventive or management principles are discussed. Conservative management is expected to be effective for most, once recommendations to massage or vibrate out lumps, which worsen micro-vascular trauma and inflammation, are ceased.

Re-thinking benign inflammation of the lactating breast: A mechanobiological model

Despite the known benefits of breastfeeding for both infant and mother, clinical support for problems such as inflammation of the lactating breast remains a research frontier. Breast pain associated with inflammation is a common reason for premature weaning. Multiple diagnoses are used for inflammatory conditions of the lactating breast, such as engorgement, blocked ducts, phlegmon, mammary candidiasis, subacute mastitis, mastitis and white spots, which lack agreed or evidence-based aetiology, definitions and treatment. This is the first in a series of three articles which review the research literature concerning benign lactation-related breast inflammation. This article investigates aetiological models. A complex systems perspective is applied to analyse heterogeneous and interdisciplinary evidence elucidating the functional anatomy and physiology of the lactating breast; the mammary immune system, including the human milk microbiome and cellular composition; the effects of mechanical forces during lactation; and the interactions between these. This analysis gives rise to a mechanobiological model of breast inflammation, in which very high intra-alveolar and intra-ductal pressures are hypothesized to strain or rupture the tight junctions between lactocytes and ductal epithelial cells, triggering inflammatory cascades and capillary dilation. Resultant elevation of stromal tension exerts pressure on lactiferous ducts, worsening intraluminal backpressure. Rising leucocyte and epithelial cell counts in the milk and alterations in the milk microbiome are signs that the mammary immune system is recruiting mechanisms to downregulate inflammatory feedback loops. From a complex systems perspective, the key mechanism for the prevention or treatment of breast inflammation is avoidance of excessively high intra-alveolar and intra-ductal pressures, which prevents a critical mass of mechanical strain and rupture of the tight junctions between lactocytes and ductal epithelial cells.

Longitudinal changes in wellbeing amongst breastfeeding women in Australia and New Zealand during the COVID-19 pandemic

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.

Possums-based parental education for infant sleep: cued care resulting in sustained breastfeeding

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.