Uninterrupted Infant Sleep, Development, and Maternal Mood

The association between infant sleep, cognitive, and psychomotor development: a systematic review

STUDY OBJECTIVES

To synthesize findings of original articles examining the association between sleep-wake patterns of typically developing infants aged 0 to 18 months and cognitive and psychomotor development.

METHODS

A systematic search strategy was used to identify articles assessing the association between infant sleep (0 to 18 months) and cognitive/psychomotor development (Medline, PsycINFO, and SCOPUS). Of 7136 articles screened, 22 articles met inclusion criteria, and the results were subsequently synthesized. A quality assessment was conducted, and studies were categorized as "poor," "fair," or "good."

RESULTS

Out of 22 studies, 2 found exclusively significant associations (SAs) between infant sleep and cognitive/psychomotor development, 2 found no SAs and 17 found mixed results (MRs). Studies with exclusively significant results used a single sleep variable and single timepoint designs. Studies finding MRs or no SAs used multiple sleep, developmental variables, or multi-timepoint designs. Eight out of 10 studies and 7 out of 8 studies investigating nocturnal and total sleep duration, respectively, found no SA with developmental outcomes. While 63% of studies were rated as having good methodological quality, all studies but one had an estimated power of less than 0.80.

CONCLUSIONS

Findings of this review do not support conclusive associations between sleep-wake patterns in infancy and cognitive/psychomotor development. This conclusion contrasts with the literature in older populations, questioning if the association between sleep and development is of a different nature in infancy, potentially because of brain maturation. More studies including larger samples will be needed to clarify the presence or absence of such an association.

Sleep-dependent memory consolidation in young and aged brains

Young children and aged individuals are more prone to memory loss than young adults. One probable reason is insufficient sleep-dependent memory consolidation. Sleep timing and sleep-stage duration differ between children and aged individuals compared to adults. Frequent daytime napping and fragmented sleep architecture are common in children and older individuals. Moreover, sleep-dependent oscillations that play crucial roles in long-term memory storage differ among age groups. Notably, the frontal cortex, which is important for long-term memory storage undergoes major structural changes in children and aged subjects. The similarities in sleep dynamics between children and aged subjects suggest that a deficit in sleep-dependent consolidation contributes to memory loss in both age groups.

Maternal depressive symptoms and mother-infant cosleeping (including room sharing and bedsharing): a systematic review

STUDY OBJECTIVES

Maternal depressive symptoms (MDS) affect most women during the first year postpartum. Mothers provide most of the nighttime care for infants, so studying the relationship between MDS and infant sleep location (ISL) is highly relevant to understanding maternal mental health over the first year of life and beyond. Infant sleep is studied by anthropologists, health care providers, and psychologists, with very little communication across disciplines. This review aimed to determine whether there is a predictive relationship between MDS and ISL.

METHODS

This systematic review searched 6 databases with terms related to maternal mood and ISL. Final analysis included 14 published studies, analyzed with narrative synthesis and Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Included studies directly compared ISL and MDS.

RESULTS

Five studies showed no relationship between ISL and MDS, and 1 study found bedsharing reduced MDS. Five studies found cosleeping was related to higher MDS although directionality is mixed or missing, and 3 studies found an association at some ages or for some populations only. Examining studies according to type of infant sleep assessment, study design, age of infant, or breastfeeding status failed to detect consistent patterns.

CONCLUSIONS

A variety of study designs, types and definitions of variable measures, sample recruitment, and study outcomes prevent detection of a consistent relationship between MDS and ISL. We explore reasons for the elusive nature of a relationship and make recommendations for future research in MDS and ISL, including crossdisciplinary collaborations.

CITATION

Barry ES, D'Souza L. Maternal depressive symptoms and mother-infant cosleeping (including room sharing and bedsharing): a systematic review. J Clin Sleep Med. 2024;20(9):1517-1533.

Maternal Sleep Quality and Executive Function are Associated with Perceptions of Infant Sleep

OBJECTIVES

This study examined the associations among maternal sleep quality, executive function, and perceptions of infant sleep in a sample of families recruited from human service and public health systems.

METHODS

Seventy-three mothers of infants 5-14 months old were included in the study. Mothers racially and ethnically identified as American Indian/Alaskan Native (4.1%), Asian (4.1%), Black/African American (12.3%), Latina (23.3%), more than one race (12.3%), Pacific Islander (1.4%), and White (42.5%). Mothers completed questionnaires assessing their own sleep (Pittsburgh Sleep Quality Index) and executive function (Behavior Rating Inventory of Executive Function) as well as their perceptions about their infant's sleep (Brief Infant Sleep Questionnaire).

RESULTS

Results of the path analysis indicated significant direct effects among maternal sleep quality, executive function, and perceptions of infant sleep. Significant indirect effects were found such that poor maternal sleep quality was linked to poorer perceptions of infant sleep through maternal executive dysfunction, adjusting for infant sleep patterns, infant age, and maternal race and ethnicity.

CONCLUSIONS

The current study highlights the potential role of maternal behavioral and cognitive factors in shaping mothers' perceptions about infant sleep. These findings support the need for health professionals and researchers to consider maternal sleep quality and executive function when addressing mothers' concerns about infant sleep.

Maternal Depression and Sleep Problems in Early Childhood: A Meta-Analysis

Both prenatal and postnatal maternal depression have been associated with increased sleep problems in early childhood. However, this association is less consistent for postnatal depression, and the strength of the association remains unclear. The aim of the current study was to provide a quantitative synthesis of the literature to estimate the magnitude of the association between maternal depression and sleep problems in early childhood. Medline, PsycINFO, PsycARTICLES, Web of Science, and Scopus were searched for prospective longitudinal studies from 1970 to December 2022. Of 117 articles screened, 22 studies met the inclusion criteria. Both prenatal depression (OR = 1.82; 95% CI = 1.28-2.61) and postnatal depression (OR = 1.65; 95% CI = 1.50-1.82) were associated with increased likelihood of sleep problems in early childhood. The heterogeneity between the studies was significant and high both for prenatal (Q = 432.323; I2 = 97.456, P < .001) and postnatal depression (Q = 44.902, I2 = 65.594, P < .001), which mean that conclusions are tentative and need to be considered within the possible influence of unmeasured confounding. However, mitigating depression symptoms in mothers both during pregnancy and in the postnatal period would be an effective strategy for reducing sleep problems in children.

The Integration of the Maternal Care with Sleep During the Postpartum Period

Our entire life occurs in a constant alternation between wakefulness and sleep. The impossibility of living without sleep implies that any behavior must adapt to the need for sleep, and maternal behavior does not escape from this determination. Additionally, maternal behavior in mammals is a highly motivated behavior, essential for the survival of the offspring. Thus, the mother has to adapt her physiology of sleep to the constant demands of the pups, where each species will have different strategies to merge these two physiological needs. However, all studied female mammals will experience sleep disturbances at some point of the postpartum period.

Maternal depression and anxiety symptoms across pregnancy and the postnatal period: Modest associations between depression symptoms and infant sleep outcomes

Maternal depression and anxiety symptoms are common across the perinatal period and are associated with a raised risk for adverse child outcomes. While substantial evidence exists for child outcomes such as behaviour, language and cognition, infant sleep has been less studied. In this longitudinal study, we examined the association between maternal symptoms of depression and anxiety and mother-reported infant sleep at 6 and 12 months. Across the four infant sleep outcomes, total sleep time, sleep onset latency, number of awakenings and a maternal perception variable, we found modest effects for concomitant depression symptoms. There were almost no additional effects for anxiety symptoms beyond that already accounted for by depression. Using trajectory modelling of maternal symptoms at five time points, we found more robust effects for maternal groups with postnatally emerging symptoms over prenatally present symptoms across all four sleep outcomes. Our strongest finding was that mothers with postnatal depression symptoms were more likely to perceive their infant's sleep as problematic compared with all other mothers. Where we found effects on duration-based infant sleep outcomes overall, these were small and clearest for depressive symptoms over anxiety symptoms. For both nighttime awakenings and perception of sleep as a problem, effects were apparent only for mothers in the postnatal symptom groups, and not for prenatal symptoms, at both infant ages six and 12 months. Our sample was a relatively high-socioeconomic group with low symptoms overall, and findings may not generalize to more vulnerable populations.

Does the feeding method affect the quality of infant and maternal sleep? A systematic review

Breastfeeding brings many benefits to both mother and infant. Although, many women stop breastfeeding their infants too soon. The perceived association between breastfeeding and sleep may influence their decision to terminate breastfeeding. In our systematic review, we focused on mapping the relationship between infant feeding method and total sleep time (TST), number of nocturnal awakenings, awakenings after sleep onset (WASO) of mothers and infants and sleep quality of mothers. We searched four databases according to selected keywords and inclusion criteria - articles published in peer-reviewed journals between 2012 and 2022; English language; a sample consisting of mothers, infants, or both (without psychiatric and health problems); a comparison of the sleep quality of breastfed and formula-fed children or breastfeeding and formula-fed mothers. We read 260 full texts of selected articles. A total of 35 articles were included in this review. Due to significant heterogeneity, meta-analysis was not possible to accomplish. The results are processed according to narrative synthesis. Most studies agree that breastfed infants wake up more often at night. Total sleep time and time spent awake during the night (WASO) did not differ between breastfed and non-breastfed infants. We observed identical results in sleep variables among mothers. Additionally, there was no difference in maternal sleep quality. The synthesis revealed that the results may have differed due to using subjective, objective methods or the infant's age. It is important to remember that night waking is a more complex concept. Infants wake for many reasons, not just due to breastfeeding. The narrative synthesis indicated that the chosen study design, measurement method, the variables, and the infant's age could influence outcomes. In addition, other variables appeared that may affect the entire process. Therefore, we recommend that attention be paid to this in future studies.

Variation in Caregiver-Reported Child Sleep Patterns and Problems by Family Socioeconomic Indicators

OBJECTIVE

Previous studies of sleep patterns, as well as rates and correlates of perceived problems in early childhood, indicate variation by neighborhood-level socioeconomic indicators. The purpose of this study was to examine variation in (1) sleep patterns, behaviors, and problems by family-based socioeconomic indicators (income-to-needs ratio and caregiver education level) and (2) sociodemographic and sleep correlates of a caregiver-endorsed child sleep problem across and within socioeconomic indicator groups in a diverse sample.

METHODS

Two hundred eighty-three caregiver-child dyads (ages 1-5 years) completed the Brief Child Sleep Questionnaire. Family-level socioeconomic indicators included income-to-needs ratio and caregiver educational level.

RESULTS

Sleep patterns varied based on income-to-needs ratio, with children living in poverty experiencing the longest sleep onset latencies and night awakening durations and shortest nighttime sleep durations. Rates of an endorsed child sleep problem were similar across income-to-needs groups. Although sleep patterns did not vary by caregiver education level, caregivers with an education beyond high school were more likely to endorse a child sleep problem; later bedtimes, more frequent night awakenings, and greater bedtime difficulties were the strongest correlates of a perceived sleep problem in this subgroup. No specific correlates of a child sleep problem emerged for those with a high school education or less.

CONCLUSION

Sleep patterns may be more robustly linked to family income-to-needs ratio, whereas perceptions of a child sleep problem may be more linked to caregiver education level. Clinicians should consider expanding sleep screening questions to include specific sleep outcomes to effectively assess child sleep and guide intervention.

Sleep of mothers, fathers, and infants: a longitudinal study from pregnancy through 12 months

STUDY OBJECTIVES

This study assessed and compared mothers' and fathers' sleep trajectories from pregnancy and throughout the first year of the infant's life. We also examined associations between maternal, paternal, and infant sleep.

METHODS

Two hundred and thirty-two couples were recruited for the study during pregnancy. Data were collected during pregnancy and at 4, 8, and 12 months postpartum. Maternal, paternal, and infant sleep were monitored at home for seven nights, using actigraphy, sleep diaries, and the Insomnia Severity Index (ISI).

RESULTS

Mothers showed more impaired sleep quality than fathers, at all assessments, whereas fathers had shorter sleep duration. Based on the ISI, about 70% of mothers and 50% of fathers showed at least subclinical insomnia at the different assessments. Trajectory analyses (controlling for feeding method and sleeping arrangements) demonstrated a significant deterioration in diary-based and actigraphy sleep quality for both parents, from pregnancy to 4 months. Both parents and infants had an increase in sleep quality from 4 to 12 months, though some parental sleep variables showed a quadratic pattern with a decrease in sleep quality at 8 months. Statistically significant triadic associations at the different assessments were found between mothers', fathers', and infants' sleep. Maternal and infant sleep measures were more strongly correlated than paternal and infant sleep.

CONCLUSIONS

The findings highlight the importance of considering the family context of sleep, by demonstrating similarities and differences in the changes that sleep undergoes in new mothers and fathers and by showing how sleep is interrelated between all family members.

The Relationship Between Maternal and Infant Sleep Duration Across the First Two Years

OBJECTIVES

The first objective of this study was to determine how mother-infant sleep duration is related across the first 2 years of life. The second objective was to determine whether these relationships change across the first 2 years of life. The third objective was to understand demographic and health predictors of the relationship between maternal and child sleep.

METHODS

Parents of 464 infants from the STRONG Kids 2 study reported their own and infants' nocturnal sleep duration and other health information (i.e., breastfeeding) at 3, 12, 18, and 24 months postpartum.

RESULTS

Latent transition models revealed 2 mother-infant sleep profiles exist at 3 to 24 months. The low maternal sleep ( LMS ) pattern was characterized by lower maternal sleep duration than the recommended amount and lower infant sleep duration. The average maternal sleep ( AMS ) pattern was characterized by average maternal sleep duration meeting the recommended standard and average infant sleep duration. Approximately half of the mothers who started in the LMS profile transitioned to the AMS profile after 12 months postpartum. The sleep profiles stabilized after 12 months postpartum with limited transitions across 12 to 24 months. More infant-signaled nighttime wakings, later bedtimes, more infant sleep problems, and more exclusive breastfeeding were predictors of being in the LMS profile.

CONCLUSION

Mother-infant sleep profiles stabilized after age 12 months, and mother-infant sleep profiles are driven by infant sleep quality during the night. The findings suggest the need to establish a healthy sleep routine for mothers and infants in the first year of life to promote longer-term sleep hygiene.

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).

The Architecture of Early Childhood Sleep Over the First Two Years

INTRODUCTION

The architecture and function of sleep during infancy and early childhood has not been fully described in the scientific literature. The impact of early sleep disruption on cognitive and physical development is also under-studied. The aim of this review was to investigate early childhood sleep development over the first two years and its association with neurodevelopment.

METHODS

This review was conducted according to the 2009 PRISMA guidelines. Four databases (OVID Medline, Pubmed, CINAHL, and Web of Science) were searched according to predefined search terms.

RESULTS

Ninety-three studies with approximately 90,000 subjects from demographically diverse backgrounds were included in this review. Sleep is the predominant state at birth. There is an increase in NREM and a decrease in REM sleep during the first two years. Changes in sleep architecture occur in tandem with development. There are more studies exploring sleep and early infancy compared to mid and late infancy and early childhood.

DISCUSSION

Sleep is critical for memory, learning, and socio-emotional development. Future longitudinal studies in infants and young children should focus on sleep architecture at each month of life to establish the emergence of key characteristics, especially from 7-24 months of age, during periods of rapid neurodevelopmental progress.

Associations between sociodemographic and behavioural parameters and child development depending on age and sex: a cross-sectional analysis

OBJECTIVES

To explore environmental and individual factors that are associated with child development and to investigate whether the strength of these associations differs according to the age of the children.

DESIGN

Cross-sectional study.

SETTING

This study was part of the LIFE Child study, a large cohort study conducted in Leipzig, Germany.

PARTICIPANTS

778 children aged between 0.5 and 6 years (48.6% girls, mean age=2.67 years).

OUTCOME MEASURES

The outcomes were cognitive development, language development, body and hand motor skills, social-emotional development, and tracing skills, measured with a standardised development test. We analysed the associations between development and gestational age, socioeconomic status (SES), sex, behavioural difficulties, siblings, sleep duration, breastfeeding duration and overweight/obesity. We also tested for interactions between these variables and child age or sex.

RESULTS

Higher gestational age (b ranging between 0.12 and 0.26) and higher SES (b ranging between 0.08 and 0.21) were associated with better outcomes in almost all developmental domains (all p<0.019). Children with older siblings had improved body and hand motor skills compared with children without older siblings (both b=0.55, all p<0.029). Boys had poorer scores than girls in body and hand motor skills and tracing (b=-0.45, -0.68 and -1.5, all p<0.019). Children with behavioural difficulties had significantly poorer outcomes in most developmental domains. Some of the associations with SES and sex were stronger in older than in younger children. Associations between gestational age and motor development were weaker in older children. We did not find significant associations between child development and sleep duration, breastfeeding duration or overweight/obesity.

CONCLUSION

Some factors had a protective, others an adverse effect on development of children under 6 years of age. The effect of SES and sex increased, while the effect of gestational age decreased with age.

TRIAL REGISTRATION NUMBER

NCT02550236.

[Sleep patterns of infants and young children and their association with breastfeeding: a study based on K-means clustering]

OBJECTIVES

To investigate the sleep patterns and characteristics of infants and young children and the association between sleep patterns and breastfeeding.

METHODS

A general information questionnaire, Brief Infant Sleep Questionnaire (BISQ), and a questionnaire on feeding were used to investigate the sleep quality and feeding patterns of 1 148 infants and young children aged 7-35 months. The K-means clustering method was used to identify sleep patterns and characteristics. A multivariate logistic regression analysis was used to investigate the association between sleep patterns and breastfeeding.

RESULTS

Three typical sleep patterns were identified for the 1 148 infants and young children aged 7-35 months: early bedtime and long sleep time; short sleep latency and moderate sleep time; late bedtime, prolonged sleep latency, and insufficient sleep time. The third pattern showed sleep disorders. The multivariate logistic regression analysis showed that compared with formula feeding, exclusive breastfeeding within 6 months after birth reduced the risk of sleep disorder patterns by 69% (OR=0.31, 95%CI: 0.11-0.81). The risk of sleep disorder patterns was reduced by 40% (OR=0.60, 95%CI: 0.38-0.96) in the infants receiving breastfeeding for 4-6 months compared with those receiving breastfeeding for 1-3 months.

CONCLUSIONS

There are different sleep patterns in infants and young children, and breastfeeding can reduce the development of sleep disorder patterns.

Racial/ethnic disparities in infant sleep in the COVID-19 Mother Baby Outcomes (COMBO) study

OBJECTIVE

Investigate racial and ethnic differences in infant sleep and examine associations with insurance status and parent-infant bedtime behavioral factors (PIBBF).

METHODS

Participants are part of the COVID-19 Mother Baby Outcomes (COMBO) Initiative, Columbia University. Data on infant sleep (night, day and overall sleep duration, night awakenings, latency, infant's sleep as a problem) were collected at 4 months postpartum. Regressions estimated associations between race/ethnicity, insurance status, PIBBF and infants' sleep.

RESULTS

A total of 296 infants were eligible (34.4% non-Hispanic White [NHW], 10.1% Black/African American [B/AA], 55.4% Hispanic). B/AA and Hispanic mothers were more likely to have Medicaid, bed/room-share, and report later infant bedtime compared to NHW mothers. Infants of B/AA mothers had longer sleep latency compared to NHW. Infants of Hispanic mothers slept less at night (∼70 ± 12 minutes) and more during the day (∼41 ± 12 minutes) and Hispanic mothers were less likely to consider infants' sleep as a problem compared to NHW (odds ratio 0.4; 95% confidence interval: 0.2-0.7). After adjustment for insurance status and PIBBF, differences by race/ethnicity for night and day sleep duration and perception of infant's sleep as a problem persisted (∼32 ± 14 minutes, 35 ± 15 minutes, and odds ratio 0.4; 95% confidence interval: 0.2-0.8 respectively). Later bedtime was associated with less sleep at night (∼21 ± 4 minutes) and overall (∼17 ± 5 minutes), and longer latency. Infants who did not fall asleep independently had longer sleep latency, and co-sleeping infants had more night awakenings.

CONCLUSIONS

Results show racial/ethnic differences in sleep in 4-month-old infants across sleep domains. The findings of our study suggest that PIBBF have an essential role in healthy infant sleep, but they may not be equitably experienced across racial/ethnic groups.

Sleep patterns and intraindividual sleep variability in mothers and fathers at 6 months postpartum: a population-based, cross-sectional study

OBJECTIVES

Given that postpartum sleep is an important family process, further investigations including both mothers and fathers are necessary. The present study aimed to describe and compare sleep patterns and intraindividual night-to-night variability in mothers and fathers at 6 months postpartum using subjective and objective sleep measures.

DESIGN

Cross-sectional study.

SETTING

General community-based study in Montreal, QC, Canada.

PARTICIPANTS

Thirty-three couples (mothers and fathers) with no self-reported history of medical and mental health conditions participated in this study.

RESULTS

Parental sleep was measured across 10 consecutive nights using both a daily sleep diary and actigraphy. Results demonstrated that mothers' subjective and objective sleep was more fragmented compared with fathers (shorter longest consecutive sleep duration and more nocturnal awakenings; p<0.001). While mothers and fathers did not differ in their self-reported nocturnal sleep duration (p>0.05), actigraphy indicated that mothers obtained significantly longer nocturnal sleep duration (448.07 min±36.49 min) than fathers (400.96 min±45.42 min; p<0.001). Intraindividual sleep variability was revealed by relatively high coefficients of variation for parents across both subjective and objective indices related to sleep fragmentation (between 0.25 and 1.32). Actigraphy also demonstrated variability by mothers sleeping 6 hours consecutively on less than 3 nights, 27.27% (±22.81), and fathers on less than 6 nights, 57.27% (±24.53), out of 10. Associations were also found between parental sleep and family factors, such as age and infant sleep location (p<0.05).

CONCLUSIONS

These findings advance our knowledge of how sleep unfolds within the family system beyond the early postpartum weeks and/or months. Given the link between disturbed sleep and family functioning, the current research accentuates the importance of examining postpartum sleep patterns and variability in parents.

Management of schizophrenia in women during the perinatal period: a synthesis of international recommendations

INTRODUCTION

The perinatal period in schizophrenia is associated with high risk of psychotic relapse and pregnancy/child outcomes. The extent to which antipsychotics may potentially affect the fetus or the child development is unclear and debated. Even though guidelines have been developed, there is a lack of consensual recommendations regarding the optimal strategy to manage schizophrenia during the perinatal period.

AREAS COVERED

This systematic review describes the current state of evidence with respect to the impact of recommended interventions for schizophrenia during the perinatal period, including childbearing age, pregnancy and post-partum. It compares recent international treatment guidelines for this specific group of women. Last, this review presents a set of major points to be discussed with patients and relatives for shared-decision making and a summary of key recommendations from the international guidelines.

EXPERT OPINION

Although treatment guidelines may be of significant help, discrepancies exist across them regarding the management of antipsychotics for schizophrenia women during the perinatal period. Shared decision-making and advance directives represent useful patient-centered approaches during this specific period. Further cohort-based evidence is needed to better identify maternal and fetal risks associated to antipsychotic treatment exposure.

Young children's sleep patterns and problems in paediatric primary healthcare settings: a multicentre cross-sectional study from a nationally representative sample

Studies describing paediatric sleep patterns are needed by taking culture into consideration. The aim of this study was to identify parent-reported sleep-wake patterns in young children and explore possible factors influencing sleep problems. The mothers of 2,434 young children enrolled from well-child outpatient clinics in Turkey completed an online survey including sociodemographic variables, Brief Infant Sleep Questionnaire, Edinburgh Postnatal Depression Scale and Generalised Anxiety Disorder scales. Overall, young children in Turkey go to bed late (10:00 p.m.), awaken twice per night for 30 min, and obtain 11.5 h of total sleep, showing no sex-specific differences. Distinct night-time sleep patterns emerged after 18 months of age. Importantly, although currently breastfed healthy children were 3.8-times less likely to sleep through the night, total sleep duration and exclusive breastfeeding duration were higher in children who were not sleeping through the night. Overall, bedsharing was identified in 11.5%, and only room sharing was reported in 52.9%. Parental perception of a child's sleep as problematic was 35.8%. Mothers with higher educational attainment were more likely to perceive their children's sleep as a problem. Maternal depressive and anxious symptoms and a history of excessive infant crying were the determinants predicting the likelihood of both parent-perceived sleep problems and poor sleepers. The present analysis of sleep structure in infancy and toddlerhood provides reference data for well-child visits. These findings highlight the importance of considering maternal anxiety, depression and behaviour management techniques to cope with fussy infants in addressing childhood behavioural sleep problems.

Effects of COVID-19 home confinement on sleep in children: A systematic review

Our main aim was to examine the evidence of the effects of coronavirus disease confinement on the sleep of children aged 12 years and younger. A systematic review was conducted following the recommendations for Preferred Reporting Items for Systematic Reviews and Meta-Analyses. MEDLINE, Cumulative Index for Nursing and Allied Health Literature, Excerpta Medica Database, Psychological Information Database, and Web Of Science were systematically searched between the period of January 2020 and March 2021. The quality assessment was analysed with the Newcastle–Ottawa quality assessment scale and the National Institutes of Health quality assessment tool for observational cohort and cross-sectional studies. The appraisal tool for cross-sectional studies was applied to cross-sectional studies and each longitudinal study was assessed with the critical appraisal skills programme. Data analysis was carried out through a narrative review. Eight studies were included in the review. Seven studies reported changes in sleep routines and five studies focused on sleep disturbances during confinement. The most important findings were a longer duration of sleep time, an increase in sleep latency, and daytime sleepiness. Whether or not the adverse changes to sleep patterns and bedtime routines seen during the home confinement period have any long-term consequences for children's sleep and daytime functioning remains unknown.

Sleep problems and infant motor and cognitive development across the first two years of life: The Beijing Longitudinal Study

The present study examined bidirectional effects between sleep problems (nocturnal awakenings and insufficient nocturnal sleep) and infant development (gross motor, fine motor, and cognition) in a sample of 182 infants (89 girls) and their parents living in Beijing (China). Using 3 waves of longitudinal data (at 6 months, 1 year, and 2 years of age), this study (a) explored the differences in sleep patterns and developmental outcomes between infants in the current sample and infants from other cultures; and primarily examined (b) whether nocturnal awakenings and insufficient nocturnal sleep prospectively predicted infant development; (c) or whether infant development predicted sleep problems. Mothers reported their children's sleep problems, and infant development was assessed with Bayley III. Sleep patterns of Beijing infants were slightly different from those from Finland and Singapore, and most scores on Bayley III in this Beijing sample were higher than those in Danish, Dutch and Sri Lankan samples. Sleep problems and developmental measures were stable across the 3 times of assessments, but cross-lagged associations were limited in number and strength. High scores on the Bayley at 6 months predicted less nocturnal awakenings at 1 year of age. Insufficient nocturnal sleep at 1 year predicted poor fine motor development at 2 years. Thus, findings suggest some bidirectional associations between infant development and sleep problems and further highlight the need to understand these relations within specific cultural contexts.

Prenatal psychosocial stress and children's sleep problems: Evidence from the ELSPAC-CZ study

Prenatal exposure to maternal stress may increase the risk of developing sleep problems in childhood. This study examined the association between prenatal stressful life events (PSLE) and children's sleep problems, taking into consideration their trajectory over time. Data were obtained from the Czech portion of the European Longitudinal Cohort Study of Pregnancy and Childhood (ELSPAC-CZ; N = 4,371 children). Mothers reported PSLE using an inventory of 42 life events and child sleep problems at five time-points (child age of 1.5, 3, 5, 7, and 11 years). The association was tested by a Poisson latent growth model, controlling for maternal and family demographics, birth characteristics, maternal depression, and alcohol use in pregnancy. The average rate of sleep problems was 2.06 (p < 0.001) at the age of 1.5 years and the rate of sleep problems decreased in a linear fashion over time (estimate = -0.118; p < 0.001). A higher number of PSLE was associated with a higher rate of sleep problems at the age of 1.5 years (incidence rate ratio [IRR] per interquartile range = 1.08, 95% confidence interval [CI] 1.05-1.12, p < 0.001) and with a reduced rate of decrease in sleep problems between the ages of 1.5 and 11 years (p < 0.001). Thus, PSLE were associated with chronicity of sleep problems in addition to their amount during early childhood. Prenatal exposure to stress may predispose individuals to the development of sleep problems in later life.

Type of Milk Feeding and Introduction to Complementary Foods in Relation to Infant Sleep: A Systematic Review

Inconsistent conclusions from infant sleep and feeding studies may influence parents feeding-related decisions. This study aimed to systematically review the existing literature on infant sleep and its relation to the timing of introduction to complementary foods and type of milk feeding to better understand their role(s) in infant sleep. Cohort, longitudinal, cross-sectional studies, and controlled trials were identified using online searches of five databases up to April 2020. Twenty-one articles with a total of 6225 infants under 12 months-of-age were eligible. Exclusively breastfed infants (≤6 months-of-age) had a greater number of night wakings, but most studies (67%) reported no difference in night-time and 24 h sleep duration compared to formula-fed infants. However, after 6 months-of-age, most studies (>65%) reported breastfed infants to sleep less in the night-time and over 24 h compared to formula-fed infants. Furthermore, studies reported no association between the timing of introduction to complementary foods and infant sleep duration (<12 months-of-age). Future studies using standardized methodologies and definitions, transdisciplinary expertise, and longitudinal design are required to better understand the complex role of feeding on sleep.

A longitudinal study of the links between maternal and infant nocturnal wakefulness

STUDY OBJECTIVES

To examine the longitudinal links between maternal and infant nocturnal wakefulness by employing a trajectory-based approach, and to assess whether the strength of these links differs as a function of sleep assessment method (actigraphy vs. self-report) and sleeping arrangements.

METHODS

Maternal and infant nocturnal wakefulness were assessed with actigraphy and sleep diaries at home for 5 nights, at 3 (N = 191), 6 (N = 178), 12 (N = 155), and 18 (N = 135) months postpartum. Outcome measures included the number of night-wakings (NW) and the length of nocturnal wakefulness (WASO).

RESULTS

Strong associations between maternal and infant nocturnal wakefulness (controlling for nighttime breastfeeding) were found for NW and WASO. Trajectory analyses demonstrated that the strength of these relations decreased linearly from 3 to 18 months. Furthermore, the findings showed that the links between maternal and infant NW and WASO were stronger for maternal reports than for actigraphy. No consistent differences were found in the strength of the relations between maternal and infant NW and WASO as a function of sleeping arrangements (ie, room-sharing vs. solitary-sleeping families).

CONCLUSIONS

The results suggest that infant and maternal sleep are strongly intertwined, especially during the first 6 months. The decline in the synchronization between maternal and infant nocturnal wakefulness through infant development may be attributed to the growing ability of infants to self-soothe during the night. The findings emphasize the need to study sleep within a family context.

The role of prior sleep for divergent thinking in infants

Higher-order cognitive functions seem particularly vulnerable to disruptions in prior sleep in school-aged children and adult populations. This study tested whether divergent thinking in infants varied as a function of prior sleep. Forty-three infants aged 13-16 months participated in a behavioural assessment of divergent thinking. Length of wakefulness since last sleep was experimentally manipulated. In addition, potential relations between divergent thinking and sleep quantity and quality during the night immediately before the assessment, as well as during three consecutive nights preceding the assessment, were examined using actigraphy recordings in combination with parent diaries. Divergent thinking was not impaired by lack of sleep within the previous 4 h. Divergent thinking was consistently related to night-time sleep quality and quantity prior to the assessment. These results suggest that timing of prior naturally occurring daytime sleep is less relevant for emergent divergent thinking capacity than quality and quantity of preceding night-time sleep.

Investigating the link between sleep and postpartum depression in fathers utilizing subjective and objective sleep measures

Background

While fathers are at risk of developing poorer sleep and depressive symptoms in the postpartum period, they represent an understudied population in the literature. The present study aimed to explore the association between sleep and postpartum depressive symptoms in fathers using subjective and objective sleep measures.

Methods

Fifty-four fathers reporting no history of depression took part in this cross-sectional study. At 6 months postpartum, paternal sleep was assessed for 2 weeks utilizing a self-report daily sleep diary, a self-report perceived sleep quality rating, and actigraphy. In the same period, depressive symptoms in fathers were assessed with the Center for Epidemiologic Studies-Depression Scale (CES-D).

Results

Regression analyses showed that paternal subjective sleep variables captured by the sleep diary (total nocturnal sleep time and number of night awakenings) were not related to postpartum depressive symptoms. However, self-reported perceived sleep quality was significantly associated with postpartum depressive symptom severity in fathers independently of demographic variables related to depression. Alternatively, the objective sleep variables (total nocturnal sleep time, number of night awakenings, sleep efficiency, and wake after sleep onset), measured by actigraphy, did not demonstrate a significant relationship with paternal depression scores.

Conclusions

These findings highlight the importance of perceived sleep quality, along with better understanding its association with postpartum depressive symptoms. Implementing a multi-measure approach enabled us to expand our knowledge about how different facets of sleep relate to postpartum depression, specifically in fathers. The results have important implications for the development of clinical interventions targeting paternal sleep and mood in the postpartum period.

Maternal Mental Health Symptoms and Clusters Predict Toddler Sleep in Low-Income Homes

The authors examined the association of maternal mental health symptoms and symptom clusters with the sleeping behaviors of toddlers living in low-income homes. The sample is comprised of 174 racially diverse mother and toddler (15-19 months old) dyads who were participating in a longitudinal birth cohort study. Dyads were initially recruited from Women, Infant, and Children clinics in a Midwestern county of the United States. Maternal mental health symptoms were measured with self-reports of depression (Center for Epidemiological Studies-Depression), parenting stress (Parenting Stress Index Very Short Form), and parenting self-efficacy. Toddler sleeping behaviors were measured with an adaptation of the Tayside Children's Sleep Questionnaire that assessed toddler difficulties in initiating or maintaining sleep (DIMS). Maternal mental health symptom clusters were identified with latent profile analysis and toddler DIMS were regressed on maternal mental health symptoms. We found that 1 SD worse maternal depression, parenting stress, or parenting self-efficacy predicted 0.18-0.24 SD worse toddler DIMS (p < .05). Moreover, we found that the cluster of adverse maternal mental health symptoms predicted nearly 0.75 SD worse toddler DIMS as compared with the cluster of good maternal mental health symptoms (p < .05). These findings provide insight into how maternal mental health symptom clusters may be important in understanding sleep behaviors in early toddlerhood, a sensitive period of sleep development, and underscore the need to support mothers with co-occurring adverse mental health symptoms, as their children may be at higher risk for DIMS.

Socioeconomic disadvantage and sleep in early childhood: Real-world data from a mobile health application

OBJECTIVES

To examine whether increased socioeconomic disadvantage, indexed using a measure of community distress, was associated with variation in caregiver-reported early childhood sleep patterns and problems in a large US sample using a mobile health application (app).

DESIGN

Cross-sectional.

SETTING

Data were collected using the free, publicly available Johnson's Bedtime© baby sleep app.

PARTICIPANTS

A total of 14,980 caregivers (85.1% mothers) of children ages 6-35.9 months (M = 13.88 months; 52.6% boys) participated in this study.

MEASURES

Caregivers reported on child sleep using the Brief Infant Sleep Questionnaire-Revised. Socioeconomic disadvantage was indexed by zip code using the Distressed Communities Index (DCI), which combines seven US census indicators of socioeconomic disadvantage. DCI scores range from prosperous (lowest quintile) to distressed (highest quintile).

RESULTS

Socioeconomic disadvantage was significantly associated with later bedtimes, longer sleep onset latency, and shorter nighttime and 24-hour (total) sleep duration, with children living in distressed communities showing the poorest sleep. However, caregivers living in distressed communities reported a significantly lower prevalence of overall child sleep problems (43% vs 58% in prosperous communities), and more confidence in managing child sleep (42% vs 34% in prosperous communities).

CONCLUSIONS

Children living in the most distressed communities have the poorest reported sleep patterns and bedtime behaviors; however, their caregivers are less likely to report problematic child sleep. These findings highlight the need for community-level sleep health promotion interventions, as well as further investigation of caregiver perceptions about child sleep and sleep health promotion among families living in socioeconomically disadvantaged contexts.

Insomnia and poor sleep quality during peripartum: a family issue with potential long term consequences on mental health

BACKGROUND

Improving maternal's health is a worldwide priority. Sleep is a fundamental operating state of the central nervous system and it may be one of the most important psychophysiological processes for brain function and mental health. The study of maternal sleep problem including insomnia, however, implies deepening our understanding of family context. Family systems are dynamic and involve reciprocal interactions among members during day and night. So far, however, maternal and children's sleep has been rarely studied in a family perspective, and paternal sleep has often been neglected.

METHODS

The present work summarizes in a narrative review the state of the art of our current knowledge on the role of insomnia and poor quality of sleep for mental health in all family members in the peripartum period. The mother, the father, the child and the family interactive perspectives are considered.

RESULTS

Insomnia and poor sleep problems are frequent in all family members during peripartum. Poor sleep and insomnia symptoms are recognized as important risk factors for mental health in adults and children. Despite this alarming evidence, sleep is rarely assessed in clinical contexts.

CONCLUSIONS

Clinical implications include the utmost relevance of assessing sleep problems during pregnancy and early post-partum. Insomnia and poor sleep quality should be evaluated and treated in the clinical practice by using a "family perspective."

Sleeping through the night or through the nights?

OBJECTIVE

There are substantial inter-individual differences in infants' longest consecutive sleep duration. However, intra-individual differences are rarely considered. The present study aimed to describe night-to-night variability in achieving 6 or 8 h of consolidated sleep over a 13-night period in 6-month-old infants.

METHODS

Forty-four typically developing infants were part of the study (22 girls). When infants were 6 months old, mothers were asked to complete an infant sleep diary over 13 nights to measure the longest period of uninterrupted sleep each night. Two criteria were used to determine if infants were sleeping through the night: 6 and 8 h of uninterrupted sleep.

RESULTS

On average, mothers reported that their infant slept 6 h consecutively for about 5 nights out of 13. Nine infants (20.5%) never slept 6 h consecutively, three (6.8%) met the criterion every night, but most infants (n = 32; 72.7%) showed high variability between the nights. Mothers reported that their infant slept 8 h consecutively for about 3 nights out of 13. Half of the infants (50.0%) never slept 8 h consecutively, one infant (2.3%) slept 8 h consecutively every night, and twenty-one infants (47.7%) showed high variability.

CONCLUSIONS

These findings expand current knowledge by showing that there is not only high inter-individual variability, but also high intra-individual variability in infant sleep consolidation. Parents and clinicians should be aware that occasional sleeping through the night does not necessarily indicate a consolidation of this behavior.

Sleep Training

Adequate sleep in infancy and beyond is important for development; however, many children are not sleeping the recommended amount. During the first few years of childhood, infants are frequently seen in the pediatric office for well-visits and a myriad of other concerns, including sleep difficulties. As such, pediatricians should be adequately prepared to address these concerns. This article aims to provide clinicians with a basic knowledge of sleep physiology, sleep patterns and development, and current guidelines and options available for parents to address these issues. [Pediatr Ann. 2020;49(3):e101-e105.].

Pre-emptive Intervention for Autism Spectrum Disorder: Theoretical Foundations and Clinical Translation

Autism spectrum disorders (ASD) are an emergent public health problem, placing significant burden upon the individual, family and health system. ASD are polygenetic spectrum disorders of neural connectome development, in which one or more feedback loops amplify small genetic, structural, or functional variations in the very early development of motor and sensory-motor pathways. These perturbations trigger a 'butterfly effect' of unpredictable cascades of structural and functional imbalances in the global neuronal workspace, resulting in atypical behaviors, social communication, and cognition long-term. The first 100 days post-term are critically neuroplastic and comprise an injury-sensitive developmental window, characterized by a neural biomarker, the persistence of the cortical subplate, and a behavioral biomarker, the crying diathesis. By the time potential diagnostic signs are identified, from 6 months of age, ASD neuropathy is already entrenched. The International Society for Autism Research Special Interest Group has called for pre-emptive intervention, based upon rigorous theoretical frames, and real world translation and evaluation. This paper responds to that call. It synthesizes heterogenous evidence concerning ASD etiologies from both psychosocial and biological research literatures with complexity science and evolutionary biology, to propose a theoretical framework for pre-emptive intervention. This paper hypothesizes that environmental factors resulting from a mismatch between environment of evolutionary adaptedness and culture initiate or perpetuate early motor and sensory-motor lesions, triggering a butterfly effect of multi-directional cascades of atypical developmental in the complex adaptive system of the parent and ASD-susceptible infant. Chronic sympathetic nervous system/hypothalamic-pituitary-adrenal axis hyperarousal and disrupted parent-infant biobehavioral synchrony are the key biologic and behavioral mechanisms perpetuating these atypical developmental cascades. A clinical translation of this evidence is proposed, for application antenatally and in the first 6 months of life, as pre-emptive intervention for ASD.