Interventions For Treating Nocturnal Crying And Night Awakening In Infants: A Critical Review

Search Strategy

Nocturnal awakening and frequent crying is one of the major problems parents had to suffer while taking care of their children. The episodes of bedtime problems and sleepless nights affects nearly 20 to 30 % of infants and toddlers worldwide. Initially parents are unaware of these problems of their children however, when the problems persists, they become intolerant and distraught (Honaker and Meltzer 2014). This severe problem of infants often persists until they grow up. The deleterious effect of nocturnal crying and night awakening in children are mood swings, attention discrepancy, poor mental and social development and aggression. The problems affects the mental growth of child and the quality of life is compromised (Hysing et al. 2014).

Due to these problems, there is a need for finding strategies or interventions of these children issues. In a research of Rickert and Johnson (1988), they found an intervention of nocturnal crying and night awakening. The intervention was scheduled awakening that was used as an effective strategy to reduce and slow but sure elimination of crying and awakening episodes in infants and toddlers. The research mainly evaluated the effectiveness of scheduled awakening by comparing it with systematic ignoring procedure. The scheduled awakening procedure is an intervention of waking up and consoling a kid at least 15 to 30 minutes before nocturnal crying and awakening to assist them in sleep consolidation. Another group, having no-treatment was included to analyze the maturation in sleep pattern.

This report critically analyzes the research done by Rickert and Johnson (1988), and compares it with four recent literature on the same issue to evaluate whether such intervention are useful in treating children issues or not. Therefore, the decision of funding depends on the critical analysis by the means of a relevant CASP tool.

There is a need to review recent research literatures, which are related to nocturnal crying and night awakening to analyze the effectiveness of scheduled awakening. It is important to find out whether same strategies or some other interventions have been used to address this problem. The strategies to search other research articles related to this topic are:

• The main strategy to find research articles related to this topic was to include those articles that has been published between 2012 and 2017.
• Second criteria was to include articles which are peer reviewed journal articles written in English and must cover the strategies to manage nocturnal awakening in kids.
• Databases used to search relevant and recent research articles were Cochrane, PubMed, CINAHL and Google Scholar.
• Key terms used to search articles were ‘ interventions for nocturnal awakening and crying’, ‘interventions for nocturnal awakening in children’, ‘crying episodes in infants’, ‘strategies for night awakening and nocturnal crying in infants and toddlers’.

These inclusion and exclusion criteria and key search terms helped to search recent review articles and evaluate different current interventions to treat these issues in children.

The following table contains the literature review of five research articles on the topic nocturnal crying and night awakening in infants.

Author	year	journal	Intervention	Key findings	notes
Rickert  and Johnson	1988	American academy of pediatrics (AAP)	Scheduled awakening and systematic ignorance	This technique can be used by parents to reduce the night awakening issues of their children	This technique is one of the prime intervention that can be used to treat children with sleep disorders
Werner et al.	2015	Journal of clinical sleep medicine (JCSM)	Zurich 3 concept was used to manage the disorder. the combination of sleep regulation, regular rhythm and adjusted bed time were used as behavioral strategy	Using this technique, night awakening in children reduced and sleep time increased	This technique can be used as an intervention to treat children with night awakening
Meltzer and Mindell	2014	Journal of pediatric psychology	Behavioral strategies such as parental education, bedtime fading, graduated extinction was assessed to regulate their effect in sleep association	This technique resulted in onset of sleep tendency and decrease in awakening frequency	The intervention lacked studies on factors needed to successfully complete the treatment
Gradiser et al.	2016	American academy of pediatrics (AAP)	Graduated extinction and bedtime fading as intervention	Sleep latency was decreased in graduated extinction and bedtime fading group whereas, number of awakening decreased in gradual extinction group	These two technique can also be used to treat children with such disorder
Price et al.	2012	American academy of pediatrics (AAP)	Behavioral sleep technique	This technique has no long term effects and parents can use these techniques fearlessly to reduce the night awakening issues of their children	Behavioral sleep technique can be used as an intervention to deal with the problem.

The research study demonstrated by Rickert and Johnson (1988) was based on Randomized Control Trial (RCT). Therefore, to critically appraise the research article, the CASP tool for RCT has been used. This CASP tool for RCT is comprised of 11 questions divided into three sections (Munn et al. 2014). The CASP for RCT has been demonstrated below:

1. Focus of the trial

According to the research article by (), a clear indication of the research topic can be identified. They have clearly mentioned the focused issue and the main purpose of the research. The prime aim of the research was to evaluate the effectiveness of the systematic ignoring and scheduled awakening techniques as interventions to decrease the night awakening and nocturnal crying episodes in infants and toddlers, used as the population of the study. The comparator group in this study was group of children with no treatment/intervention. The considered outcome was to evaluate the effects of used interventions.

1. Treatment was randomized or not

Literature Review

As per the norms of RCT studies, the trial group as well as the control group has to be allocated randomly. Once this process is correct and completed, the biasness in the system reduced drastically. Hence, the prime critical aspect of conducting RCT is developing random categorization and screening of participants prior the commencement of the treatment (Ivers et al. 2012). In the examined research article, the participants of RCT included 33 children, having an average age of 20 months. All these participants were recruited via local newspaper advertisements. Even the assignment of children to one of the groups between treatment group and Control group was done randomly and after that home visit was conducted. therefore, the allocation of the children was screened by researchers as parents of those participating children was unaware of the group they were in. they were informed after the 9 weeks of trial and once the data was collected. The data was comprised of the daily schedule of the child such as feeding time, sleep duration, night awakening and crying duration and so on.

1. Treatment of patients who entered the trial

The researchers, to evaluate the fact that whether all the members who entered the trial were appropriately accounted for its assumption, carried out proper follow up of participants. The researchers also analyzed the outcomes in children assigned to a specific group. However, during the study differences in treatment has been found. At first, the children were assigned to any one of the groups between trail and control. Furthermore, few children from each group opted out from the trial. Hence, total 33 children were left out of 56. Finally, all the parents were asked to report one week prior to treatment/trial, to ensure proper analysis of both the groups. This process helped the researchers to maintain a baseline data of the study. Maintenance of baseline data in such research is important as it helps to interpret the data effectively (Deke and Puma 2013).

1. Patients, health and study personnel were blind to treatment

To conduct a successful RCT, blinding procedure is important. This process prevents the participants and healthcare workers involved from understanding the kind of intervention they were given. However, practically such process is impossible in clinical trials as to determine the success of such research, complete engagement of the participant is important. According to the examined study of Rickert and Johnson (1988), the trail group and the control group was finalized randomly, that indicates to the fact that the treatment and intervention was obscured from them. However, it is difficult to state that they were blind to the intervention as well. The groups were informed about all the research scenario, once the data was collected. Therefore, open labeling has been identified instead of blinding in this study, leading to biasness. In a RCT conducted by Douglas and Hill (2013) to screen the effectiveness of behavioral sleep in kids, selection of participants was based on the problems reported by their parents. While the difference from the examine study was, researchers in case were blind to the group allocation, instead of parents.

1. Groups were similar at the commencement of trial or not

Critical Appraisal using CASP tool

Evaluation of the RCT study is done by assessing the similarity of trial groups. Similarity is denoted by baseline factors such as sex, age, socio-economic status, health status and educational status. Maintaining these baseline factors are critical as it influences study outcomes, determines validity of the study and effects the intervention as well (Savovi? et al. 2014). Rickert and Johnson (1988) maintained the similarity in their research as they took children in age group of 6 to 54 months. However, there was biasness in the study, as social factor was not maintained. There were children having single parents as well as double parent. Educational baseline was also not maintained in the study.

1. The group was treated equally or not

Apart from equal appliance of trial intervention, other factors that can affect the results of trial or performance of the participant need to treated equally. Rickert and Johnson (1988) also treated their participants equally by using exclusion criteria to finalize the participants. The researches eliminated all the other factors that can affect the prime interventions of the study; systematic ignorance and scheduled awakening. Therefore, they excluded those parents who were not concerned about one of this problems their child was facing. The children who were resistant to sleep were excluded as well. Researchers also taken into account the number of nights and time duration of night awakening of all the participants to provide equal treatment to all of them (Almirall et al. 2012).

1. Effect of the treatment

The effectiveness of the treatment was determined by comparing the outcomes in trail group and control group. The prime aim was to determine the decreased amount of night awakening and nocturnal crying in these groups. After comparison, it was found that participants of systematic ignoring group showed positive outcomes in 8 weeks, which was the fastest among all. Scheduled awakening was also found to be effective however; the Rate of improvement was slow in this case. Hence, the period at which prime differences were noticed was observed in week 3, 4, 5, 6 and 7. The pyramid of successful intervention can be stated as: systematic ignoring scheduled awakening and at last the no treatment group. In a similar research done by Halal and Nunes (2014) it was found that systematical ignorance to the demand of children to a specific period could effectively improve their sleep pattern.

1. Estimation of the treatment effect

Interval of confidence and size of effect determines the accuracy of the trial effect in RCT. narrow confidence interval denotes accurate results as well as the wider confidence interval denotes uncertain trial results. During the evaluation of the research of Rickert and Johnson (), it can be said that wide confidence was present in the study because variability in control group development trends were noticed. The group with no treatment also showed improvement and that is a subject for research as well. In spite of such limitations, the research was successful to introduce the intervention used to treat nocturnal crying and awakening in children. In a study by Gregory and Sedah (2012), it was proved that systematic ignorance and scheduled awakening was able to improve the condition of children.

1. Application of the result

The valid and effective evidence of application of the intervention, used in the research on local population successfully, can understand success of any research. The transferability and efficacy of the research is high if it can be applied to a large population without any difficulty. In this research article, systematic ignoring emerges, as the best intervention to treat the issues, however, the chances of its application in local population is less. According to studies, several parents are unable to ignore their children crying, which is a treatment process to reduce night awakening. Many parents may not prefer ignoring their child’s cry as an appropriate treatment to reduce night awakening period. There is evidence also which have showed that parents strongly resist employing the systematic ignoring approach for their child (Etherton, Blunden and Hauck 2016). Therefore, it can be stated that scheduled awakening can be used in local population, as it is easy to apply. There is a need to conduct more research on strategies to affect the sleep of the children positively, using systematic ignorance technique.

1.  Clinical outcome consideration

In case of nocturnal crying and night awakening, the clinically significant outcome was decreasing the duration of nocturnal awakening and frequency of awakening in children. The research of Rickert and Johnson (1988) proved the efficacy of systematic ignoring and scheduled awakening by clinical outcomes as well. For example, after implementation of this intervention on kinds, dramatic improvement in frequency of awakening was noticed. Therefore, clinical outcome of this research for children was positive. However, for parents the stress level enhanced even after the application of intervention (Meltzer et al. 2012).

1. Values of benefit

This RCT of research worth all the time and cost investment as at last successful interventions was discovered. This research provided huge response as parent applied these interventions on their children and get positive results. Hence, on ground level as well the research become successful. However, the prime limitation of this experiment was slower effects and identifying correct intervention for each children to get positive outcomes associated with it (Moore 2012).

Conclusion

The report discussed the prime reasons of nocturnal crying and night awakening in children and assessed its impact on the child as well as on the health of their parents. This report critically appraised the research article of Rickert and Johnson (1988), compared it with four similar research articles, and conducted a literature review on these papers. Finally, it was revealed that systematic ignorance and scheduled awakening is beneficiary for children having such issues. Literature review also points out the fact that scheduled awakening can be used on local population as it shows faster and positive results on ground as well. Hence, it can be recommended that more research should be conducted to successfully apply these interventions in society. Proper research can figure out the loopholes that affects the implementation of these interventions on children with such disorders in society.     

References for literature review

Gradisar, M., Jackson, K., Spurrier, N.J., Gibson, J., Whitham, J., Williams, A.S., Dolby, R. and Kennaway, D.J., 2016. Behavioral interventions for infant sleep problems: A randomized controlled trial. Pediatrics, p.e20151486.

Meltzer, L.J. and Mindell, J.A., 2014. Systematic review and meta-analysis of behavioral interventions for pediatric insomnia. Journal of Pediatric Psychology, 39(8), pp.932-948.

Price, A.M., Wake, M., Ukoumunne, O.C. and Hiscock, H., 2012. Five-year follow-up of harms and benefits of behavioral infant sleep intervention: randomized trial. Pediatrics, 130(4), pp.643-651.

Rickert, V.I. and Johnson, C.M., 1988. Reducing nocturnal awakening and crying episodes in infants and young children: a comparison between scheduled awakenings and systematic ignoring. Pediatrics, 81(2), pp.203-212.

Werner, H., Hunkeler, P., Benz, C., Molinari, L., Guyer, C., Häfliger, F., Huber, R. and Jenni, O.G., 2015. The Zurich 3-step concept for the management of behavioral sleep disorders in children: a before-and-after study. Journal of clinical sleep medicine: JCSM: official publication of the American Academy of Sleep Medicine, 11(3), p.241.

References 

Almirall, D., Compton, S.N., Gunlicks?Stoessel, M., Duan, N. and Murphy, S.A., 2012. Designing a pilot sequential multiple assignment randomized trial for developing an adaptive treatment strategy. Statistics in medicine, 31(17), pp.1887-1902.

Calvert, M., Blazeby, J., Altman, D.G., Revicki, D.A., Moher, D., Brundage, M.D. and CONSORT PRO Group, 2013. Reporting of patient-reported outcomes in randomized trials: the CONSORT PRO extension. Jama, 309(8), pp.814-822.

Deke, J. and Puma, M., 2013. Coping with missing data in randomized controlled trials. Mathematica Policy Research.

Douglas, P.S. and Hill, P.S., 2013. Behavioral sleep interventions in the first six months of life do not improve outcomes for mothers or infants: a systematic review. Journal of Developmental & Behavioral Pediatrics, 34(7), pp.497-507.

Etherton, H., Blunden, S. and Hauck, Y., 2016. Discussion of extinction-based behavioral sleep interventions for young children and reasons why parents may find them difficult. Journal of clinical sleep medicine: JCSM: official publication of the American Academy of Sleep Medicine, 12(11), p.1535.

Gregory, A.M. and Sadeh, A., 2012. Sleep, emotional and behavioral difficulties in children and adolescents. Sleep medicine reviews, 16(2), pp.129-136.

Halal, C.S. and Nunes, M.L., 2014. Education in children’s sleep hygiene: which approaches are effective? A systematic review. Jornal de pediatria, 90(5), pp.449-456.

Honaker, S.M. and Meltzer, L.J., 2014. Bedtime problems and night wakings in young children: an update of the evidence. Paediatric respiratory reviews, 15(4), pp.333-339. 

Hysing, M., Harvey, A.G., Torgersen, L., Ystrom, E., Reichborn-Kjennerud, T. and Sivertsen, B., 2014. Trajectories and predictors of nocturnal awakenings and sleep duration in infants. Journal of Developmental & Behavioral Pediatrics, 35(5), pp.309-316.

Ivers, N.M., Halperin, I.J., Barnsley, J., Grimshaw, J.M., Shah, B.R., Tu, K., Upshur, R. and Zwarenstein, M., 2012. Allocation techniques for balance at baseline in cluster randomized trials: a methodological review. Trials, 13(1), p.120.

Meltzer, L.J., Montgomery-Downs, H.E., Insana, S.P. and Walsh, C.M., 2012. Use of actigraphy for assessment in pediatric sleep research. Sleep medicine reviews, 16(5), pp.463-475.

Moore, M., 2012. Behavioral sleep problems in children and adolescents. Journal of clinical psychology in medical settings, 19(1), pp.77-83.

Munn, Z., Moola, S., Riitano, D. and Lisy, K., 2014. The development of a critical appraisal tool for use in systematic reviews addressing questions of prevalence. International journal of health policy and management, 3(3), p.123.

Savovi?, J., Weeks, L., Sterne, J.A., Turner, L., Altman, D.G., Moher, D. and Higgins, J.P., 2014. Evaluation of the Cochrane Collaboration’s tool for assessing the risk of bias in randomized trials: focus groups, online survey, proposed recommendations and their implementation. Systematic reviews, 3(1), p.37.