Evaluation And Management Of Sleep Disorders In Infants

Search protocol

Discuss About The Evaluation Of Sleep Disorders In Infants?

One of the common and significant issues faced by the parents are the not sleeping behaviour throughout the night and thereby restricting from going to sleep by their children (Sivertsen et al., 2015).  The persistence of the sleep disruptions with crying episodes led to negative impacts on the parents such as distress, fatigue and decrease in the tolerance towards the night time problems (O’Neill & Gilea, 2017). The other part of concern was that some of the parents who faced the issues regarding episodes of crying in night by infants did not consult any professionals to solve the problem (Bell, 2014). The difficulties faced in the bedtime sleep led to child abuse, maternal ambivalence and maternal depression towards their child (Weinraub et al., 2012). Keeping this issue into consideration, professional support played major role in solving the spontaneous awakening and crying phases in night further preventing the conflict of parent-child (Mindell & Owens, 2015).

In this review, different databases were considered such as MEDLINE, SCOPUS, EMBASE, CINAHL and Cochrane Library. The search terms were “child,” “toddler,” “infant,”  “sleep,” “settling,” “wake,” “treatment,” “medication,” “therapy,” and “intervention”. The searching pattern was supplemented through tracking all the articles and cited reviews, bibliography, books as well as hand searching the journals based on the topic for the last 5 years. 

The studies that were included in this review were centred within young children aged 5 or younger, who represented nocturnal awakening at night time, with established sleep problems and crying episodes. Settling these infants to bed was generally followed by tantrums and was recognized as problematic by their respective parents. Non-randomized control trials were selected. The review includes journals that focus on study of specific outcome measures, which included settling time, night time awakening episodes and relationship with emotional availability of mothers. The journals considered were all peer reviewed and published in English language. The journals with publication date not prior to 2012 were selected. The exclusion criteria comprised the articles that were non- English journals, published abstracts, dissertations and those with publication date before 2012.

Prenatal factors that influenced the frequent awakening and crying in the night-time in a regular basis by the infants included breastfeeding, temperament, parental attention, family distress, colic and physical illness followed by poor sleep (St James-Roberts, 2013).  Though suggestions regarding managing the issue had been evaluated but 2126 randomized interventional controlled trials were not conducted for the crying episodes and night-time awakening in the infants. The different suggestive ideas regarding reducing the problem included modification in diet, sedation with gradual ignoring of the crying episodes (Richardson & Friedman, 2016). With this respect, only few procedures among which included a new technique known as scheduled awakenings had been examined which resulted effectively causing the infant to preclude frequent nocturnal awakening and episodes of crying (Young, 2016). 

Inclusion and exclusion criteria

It was found that scheduled awakening and systemic ignoring effectively reduced the nocturnal awakening and crying phases in infants. The systemic ignoring causing the infants “cry it out” was recommended to be very effective by the pediatrician showing the fastest improvement.  The control group children showed general decreased awakening but some were still showing the spontaneous night awakening (Weissbluth, 2015). These proved that some infants recover over time. It was found that out of 11 infants 4 showed no awakening after 8 weeks and after the last follow-up only half of them recorded to be awakened once a week. Age played no role in the process both all the groups. Some of the parents related that they ignored the crying and waited for their child to stop crying. This strategy of lengthening the time of crying was found similar to the studies of Ferber (Kuhn, 2014).  Of the 11 infants in control, 7 infants that showed reduced nocturnal awakenings with significant results of time effects which could be measured by videotaping.

Due to lack of significant difference in between systemic ignoring and scheduled awakening except at 3 week both were encouraged, although the second one being reported to be slower. This resulted for a suggestion of an alternative effective process other than ignoring (GUIDE, 2014). Although some parents feared to wake their infants in scheduled process, all 11 went back to sleep after some time precluding the spontaneous awakening in night. As the parents found it more affective in precluding the spontaneous awakening, they made no complains in implementing the scheduled awakening strategy (Schnoes, 2016). But one of the limitations of the present study restricted the evaluation of a better treatment protocol of standard awakenings as in most of the studies it was just an educated guess of the awakening length (Turner, 2012). 

At the initial stage 50 children were assigned randomly to one out of three conditions that scheduled awakenings, systematic ignoring or control. 17 infants were excluded for different reasons as given in appendix A (Moore, 2012).

Thus, only some of the investigators had successfully evaluated the techniques but none of them were systematically studied through a randomized study of clinical control. No hypothetical view was considered regarding the efficacy of one treatment with respect to the other one (Bolten, 2013).

The trials of the studies are assessed in an independent way and in a non blinded manner. The critical appraisal tool assesses 4 similar kinds of studies that illustrated the effectiveness of intervention methods on sleep disturbances and nocturnal wakening among infants. The tool analyses the focus of study, follow-up strategies, outcome measures, equal treatment for all patients, significance and precision of the treatments and their applicability in local population.

Parameters	Sheridan et al., 2013	Jin, Hanley & Beaulieu, 2013	Rickert and Johnson, 1988	Philbrook & Teti, 2016
Did the trial address a clearly focused issue?	Yes (investigated persistence of sleep disturbances in childhood and influence by maternal setting strategies)	Yes (investigated the effects of assessment based intervention strategies on treating sleep disturbances in infants, 2 of them had autism)	Yes (investigated the effectiveness of systematic ignoring and scheduled awakening on reducing crying episodes and spontaneous awakening in toddlers and infants)	Yes (examined the bidirectional and longitudinal linkage between infant sleep patterns and bedtime parenting practices during first 6 months post-partum using multivariate model analysis)
Was the assignment of patients to treatment non-randomized?	Yes (Mothers with psychosocial adversity were enlisted)	Yes (3 children aged 7-9 years and their parents were recruited)	Yes (33 infants with mean age of 20 months and 14 events of spontaneous awakening every week were enlisted)	Yes (Mothers were enlisted from local hospitals after giving birth to infants. 167 infants who were 1 month old and their parents were recruited.
Were all patients accounted for at conclusion?	Yes (measurement of sleep characteristics till 5years of age)	Yes (infrared night time videos, sleep diaries were used to evaluate measures of behaviours that intervene sleep patterns, parental presence, effect of medical administration, night waking and total sleep)	Yes (all infants and their parents were subjected to treatment for 56 days)	Yes (Follow up was done when the infants were 3 months old and 6 months old)
Were patients, health workers and study personnel blind to treatment?	No	Can’t tell	No	No (Final sample was based on 109 mothers and their infants due to unavailability of bed time data scores from several families)
Were the groups similar at start of trial?	Yes	Yes (Walter was 7 years old and experienced delay in sleep onset; Andy was 9 years old and had been diagnosed with Autism spectrum disorder. He reported night awakenings and sleep onset delay; The third patient Lou was 9 years old and faced difficulty to fall asleep., He woke up in the middle of night and got out of bed)	Yes (21 two parent families and 6 single parent families were recruited; 18 boys and 15 girls reported same number of spontaneous awakening events per week; all parents were high school graduates; 12 families had parents who were college pass outs)	Yes (84% mothers were married and lived with their partners; the average age of the mothers was 29.9 years in the range 19-43 years old; 90% mothers had completed post secondary education and 57% were employed)
Were the groups treated equally?	Yes	Yes (study was conducted at their homes under parent surveillance. All children were made to sleep in their own bedrooms without their siblings. The bedrooms were either dimly lit or dark. All parents documented their child’s sleep patterns and events of night awakenings, sleep resumption, morning awakening, naps during a 24 hour cycle. A cam recorder recorded the children’s night time behaviour to support the evidence documented by their parents. However, one limitation was that the camera recorded events that occurred near the child’s bed only.	Yes (all parents were engaged in telephonic conversations and were made to collect data of their child’s daily schedule; they were instructed not to change any treatment patterns for the duration of the study; fathers were made to record data for a day every week during baseline measures, treatment and follow up; parents recorded physical reasons for their infant’s crying; they did not provide feeding bottles or breast feed their child during such episodes; no parents reported scheduled awakening by the 2nd follow up)	Yes (Video cameras were placed inside the house to capture the interaction between parents and infants during bed time and record the place where the infant was taken upon night awakening; Emotional Availability Scales were used to assess maternal emotions during infant bedtime- 4 scales based on structuring, sensitivity, non-hostility and non-intrusiveness were measured; presence or absence of close contact, arousing activities, co-sleeping with parents, infant distress and breast feeding were measured for each 30 second interval; all mothers had to complete a maternal depression survey based on 13 questionnaire items, sleep quality among all mothers was assessed for 7 days using a mini-mitter actigraphy wristwatch)
How large was the treatment effect?	Sleep disturbances persisted till five years in high risk infants. Maternal involvement was found to be larger in mothers at a high risk mothers in infant setting and predicted less optimal sleep at five years.	Agreement data collected was 43% and 24% for delay in sleep onset; 36% and 28% for overall sleep interfering behaviour; 25% and 22% for specific sleep interfering behaviour. Partitioning the duration of observation into 10 second intervals and converting the results to percentages gave the average for all intervals.	1 way variance analysis were performed between the groups; baseline data for treatment groups were compared to number of awakening episodes; 3*8 multivariate analysis was performed with 1 between factor (groups) and 1 within factor (weeks).	SAS 9.4 and Proc Mixed were used for multilevel model analysis. Hypothesis 1-3 predicted night time distress in infants by analysing parent variables, hypothesis 4 predicted parenting practice and maternal EA by focusing on infant variables. 88% infants and 66% parents provided data for at least 2 time points.
How precise was the estimate of treatment effect?	Less optimal sleep at the age of 5 years was predicted	Mean agreement for sleep onset delay was 95%, vocalization was 97%, out of bed was 99%, sitting up was 97% and for stereotypy was 99%. Sleep onset delay was highly variable in baseline. Sleep goals were met during treatment intervention in all children compared to baseline. Average rating of social acceptability for all 3 families was 6.8 on a 7 point Likert scale.	No significant age differences found between groups (P>0.05); crying episodes and night time awakening did not vary before intervention (P>0.05); multivariate analysis showed significant changes for groups (P<0.03) and for weeks (P<0.01); significant differences were observed across time for weeks 2,3,4 and 5 (P<0.05)	Night time distress reduced with age (P<0.0001); quadratic component was significant (P<0.001); emotionally available mothers had infants with less distress (P=0.06); infants who co-slept with parents were less distressed (P= 0.058); Significant interaction observed between nursing, maternal EA and quadratic changes (P<0.05); infant sleep increased over time in linear estimate (P<0.001); it leveled off after 3 months according to quadratic estimates (P<0.001); Less sleep was associated with arousal activities (P<0.05); infants slept less whose mothers were less emotionally available (P<0.05)
Can the results be applied in this context?	Yes (parents should be supported in settling practices that will directly influence optimal sleep in their children).	Yes	Yes (results suggest that effective alternatives exist to systemic ignoring practices)	Yes (maternal EA, less close contact and parental interactions  can be linked to more sleep and less distress among infants)
Were all clinically important outcomes considered?	Yes	Yes (these measures should be simultaneously used along with video recordings to calibrate the measurements. Video recordings may be intrusive but they assist in making precise measurements when used in combination with parent diaries)	Yes (systemic ignoring was more effective than scheduled awakening during first week of treatment)	Yes (the study focused on the complex interplay between parenting activities and infant night time distress; However, parenting practices can change across cultures. The study was based largely on Caucasian population. Thus, changes are expected when applied across other populations)

Prenatal Factors Contributing to Sleep Disturbances in Infants

• Appendix B – The average count of night time awakenings through the three conditions are provided which showed that the systemic ignoring technique showed more efficacy in reducing the awakening in the infants through 8 weeks of treatment.
• Appendix C- The points at which the three groups differed in the treatment were evaluated through a range of analysing 8 variances that were conducted for each treatment week.
• Appendix D- The scatter plot analysis is provided to represent the count of awakening and crying episodes through the treatment weeks with respect to 33 children. Each point represented a child and the data indicated a wide variable among the control and the documented developmental trends.
• Appendix E- Demonstrates a broader literature search and key findings.

Conclusion

Thus, from the above review it can be concluded that systemic ignoring plays an effective role in reducing the night time awakening and crying phases in the infants. It reduced the spontaneous awakenings frequency rapidly but the awakenings duration was found to rise initially which became unacceptable to some parents. Alternative technique, scheduled awakenings were found to be more viable to some of the parents. But as this technique was slower, the efficacy stayed unclear. Other factors such as change in sleep cycle, shaping and controlling stimulus successfully eliminated the awakenings in the night time during the use of scheduled awakenings. But before delivering scheduled awakenings technique more studies should be conducted to make understand the other non expert professionals. Apart from this, it could be said that both the systemic ignoring and the scheduled awakenings showed more effective results rather than to see the child outgrow the problematic behaviour. Lastly both the treatment strategies must be compared with modified diet, medication and delayed progression in the parents attention to retain relative efficacy. To successfully implement the strategies to reduce the spontaneous night time awakenings followed by reduced crying phases in the children, proper funding should be provided in order to conduct the interventions properly and effectively as it involves different stages of treatment with follow-ups after the treatments.

References

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