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1.  Daytime Sleep and Parenting Interactions in Infants Born Preterm 
Objective
Following a transactional perspective, this longitudinal study assessed concurrent and time-lagged associations between infant daytime sleep behaviors and maternal play interactions within a sample of infants born preterm.
Method
Data were collected from 134 families recruited from 3 Wisconsin NICUs. Multiple methods were used to collect data at infant NICU discharge and when infants were 4, 9, and 24 months postterm, including parent-report infant sleep logs, family sociodemographic assets and a 15 minute video-taped play session.
Results
Within time points, infants who napped more had mothers who were rated as more positive and communicative or less negative during play interactions at 4, 9 and 24 months compared to infants who napped less. Time-lagged findings indicated that infants who took more naps experienced more optimal maternal interactive behaviors later in development than infants who took fewer naps. Additionally, mothers who expressed more negative affect at 4 months or 9 months predicted more infant daytime sleep later in development.
Conclusion
Previous studies document that nighttime parent-child interactions influence nighttime sleep. This study presents the natural extension that daytime sleep influences daytime interactions. The present study draws attention to the understudied area of daytime naps in young children and provides support for the longitudinal bi-directional processes between sleep and parenting interactions.
doi:10.1097/DBP.0b013e3181fa57e4
PMCID: PMC3072039  PMID: 20978444
Preterm; Sleep; Parenting
2.  Baby Business: a randomised controlled trial of a universal parenting program that aims to prevent early infant sleep and cry problems and associated parental depression 
BMC Pediatrics  2012;12:13.
Background
Infant crying and sleep problems (e.g. frequent night waking, difficulties settling to sleep) each affect up to 30% of infants and often co-exist. They are costly to manage and associated with adverse outcomes including postnatal depression symptoms, early weaning from breast milk, and later child behaviour problems. Preventing such problems could improve these adverse outcomes and reduce costs to families and the health care system. Anticipatory guidance-i.e. providing parents with information about normal infant sleep and cry patterns, ways to encourage self-settling in infants, and ways to develop feeding and settling routines before the onset of problems-could prevent such problems. This paper outlines the protocol for our study which aims to test an anticipatory guidance approach.
Methods/Design
750 families from four Local Government Areas in Melbourne, Australia have been randomised to receive the Baby Business program (intervention group) or usual care (control group) offered by health services. The Baby Business program provides parents with information about infant sleep and crying via a DVD and booklet (mailed soon after birth), telephone consultation (at infant age 6-8 weeks) and parent group session (at infant age 12 weeks). All English speaking parents of healthy newborn infants born at > 32 weeks gestation and referred by their maternal and child health nurse at their first post partum home visit (day 7-10 postpartum), are eligible. The primary outcome is parent report of infant night time sleep as a problem at four months of age and secondary outcomes include parent report of infant daytime sleep or crying as a problem, mean duration of infant sleep and crying/24 hours, parental depression symptoms, parent sleep quality and quantity and health service use. Data will be collected at two weeks (baseline), four months and six months of age. An economic evaluation using a cost-consequences approach will, from a societal perspective, compare costs and health outcomes between the intervention and control groups.
Discussion
To our knowledge this is the first randomised controlled trial of a program which aims to prevent both infant sleeping and crying problems and associated postnatal depression symptoms. If effective, it could offer an important public health prevention approach to these common, distressing problems.
Trial registration number
ISRCTN: ISRCTN63834603
doi:10.1186/1471-2431-12-13
PMCID: PMC3292472  PMID: 22309617
3.  Nighttime sleep-wake patterns and self-soothing from birth to one year of age: a longitudinal intervention study 
Background
The objectives of this study were to: (1) describe the longitudinal development of sleep-wake patterns of solitary-sleeping infants from 1 to 12 months of age, (2) identify effects on sleep patterns and on self-soothing behaviors of introducing a novel sleep aid, and (3) identify predictive factors of self-soothing at 12 months using a transactional model as a guide.
Methods
Eighty infants’ nighttime sleep-wake patterns and associated variables were studied at 5 times across the first year of life using videosomnography and questionnaires.
Results
Sleep-wake state developmental changes, as reported in investigations of infant sleep, were replicated, although a great deal of individual variability in the development of all sleep-related variables was noted. No major effects on sleep or on self-soothing behavior were evident from the introduction of the novel sleep aid. Three variables were identified as significant predictors of self-soothing at 12 months: decreasing amounts of time spent out of crib across the first year, high levels of quiet sleep at birth, and longer parental response times to infant awakenings at 3 months.
Conclusions
These data lend preliminary support for the transactional model and suggest that infant and parental factors interact to influence the development of self-soothing.
PMCID: PMC1201415  PMID: 12236607
Infancy; normal development; parent-child interaction; paediatrics; sleep; temperament; AS: active sleep; AW: wakefulness; BDI: Beck Depression Inventory; GLM: general linear modeling; LSP: longest sleep period; OOC: out of crib; PSOCS: Parenting Sense of Competence Scale; QS: quiet sleep; RSA: representational sleep aid; SC: sham control; SS: self-soothed; TST: total sleep time
4.  Maternal Caffeine Consumption and Infant Nighttime Waking: Prospective Cohort Study 
Pediatrics  2012;129(5):860-868.
OBJECTIVE:
Coffee and other caffeinated beverages are commonly consumed in pregnancy. In adults, caffeine may interfere with sleep onset and have a dose-response effect similar to those seen during insomnia. In infancy, nighttime waking is a common event. With this study, we aimed to investigate if maternal caffeine consumption during pregnancy and lactation leads to frequent nocturnal awakening among infants at 3 months of age.
METHODS:
All children born in the city of Pelotas, Brazil, during 2004 were enrolled on a cohort study. Mothers were interviewed at delivery and after 3 months to obtain information on caffeine drinking consumption, sociodemographic, reproductive, and behavioral characteristics. Infant sleeping pattern in the previous 15 days was obtained from a subsample. Night waking was defined as an episode of infant arousal that woke the parents during nighttime. Multivariable analysis was performed by using Poisson regression.
RESULTS:
The subsample included 885 of the 4231 infants born in 2004. All but 1 mother consumed caffeine in pregnancy. Nearly 20% were heavy consumers (≥300 mg/day) during pregnancy and 14.3% at 3 months postpartum. Prevalence of frequent nighttime awakeners (>3 episodes per night) was 13.8% (95% confidence interval: 11.5%–16.0%). The highest prevalence ratio was observed among breastfed infants from mothers consuming ≥300 mg/day during the whole pregnancy and in the postpartum period (1.65; 95% confidence interval: 0.86–3.17) but at a nonsignificant level.
CONCLUSIONS:
Caffeine consumption during pregnancy and by nursing mothers seems not to have consequences on sleep of infants at the age of 3 months.
doi:10.1542/peds.2011-1773
PMCID: PMC3566755  PMID: 22473365
sleep; sleep duration; infant sleeping; night waking; infant; caffeine; coffee
5.  Sleep and breathing in premature infants at 6 months post-natal age 
BMC Pediatrics  2014;14(1):303.
Background
Poor sleep contributes to the developmental problems seen in preterm infants. We evaluated sleep problems in preterm infants 6 months of post-gestational age using the subjective Brief Infant Sleep Questionnaire (BISQ) and objective sleep tests. We also compared the sleep of premature infants with that of full-term infants.
Methods
The study included 68 6-month-old full-term healthy infants and 191 premature infants born at <37 weeks gestation. All parents completed the BISQ-Chinese version and sleep diaries. At the same time, all premature infants were submitted to one night of polysomnography (PSG) in the sleep laboratory and also were set up with an actigraph kept for 7 days. Statistical analyses were performed using correlation coefficients and the t-test with SPSS version 18 to compare questionnaire responses with other subjective and objective measures of sleep.
Results
The sleep problems indicated in the subjective questionnaire for the premature infants, particularly: “the nocturnal sleep duration, number of night awakenings, daytime sleep duration, duration of time with mouth breathing, and loud-noisy breathing” had significant correlations with sleep diaries, actigraphy and PSG results. The BISQ showed that duration of infant’s sleeping on one side, nocturnal sleep duration, being held to fall asleep, number of nighttime awakenings, daytime sleep duration, subjective consideration of sleep problems, loud-noisy breathing, and duration spent crying during the night were significantly different between the premature infants and the term infants. PSG confirmed the presence of a very high percentage (80.6%) of premature infants with AHI > 1 event/hour as indicated by the questionnaire.
Conclusion
Premature infants have more sleep problems than full-term infants, including the known risk of abnormal breathing during sleep, which has been well demonstrated already with the BISQ-Chinese (CBISQ).
Electronic supplementary material
The online version of this article (doi:10.1186/s12887-014-0303-6) contains supplementary material, which is available to authorized users.
doi:10.1186/s12887-014-0303-6
PMCID: PMC4272529  PMID: 25510740
Sleep questionnaire; Sleep-disordered breathing; Prematurity; Full-term infant
6.  The Effects of Napping on Cognitive Function in Preschoolers 
Objective
To determine the relationship between napping and cognitive function in preschool-aged children.
Methods
Daytime napping, nighttime sleep and cognitive function were assessed in fifty-nine typically developing children ages 3-5 years, who were enrolled in full-time childcare. Participants wore an actigraphy watch for 7 days to measure sleep and napping patterns, and completed neuropsychological testing emphasizing attention, response control, and vocabulary. Parents of participants completed behavior ratings and sleep logs during the study. Sleep/wake cycles were scored with the Sadeh algorithm.
Results
Children who napped more on weekdays were also more likely to nap during weekends. Weekday napping and nighttime sleep were inversely correlated, such that those who napped more slept less at night, while total weekday sleep remained relatively constant. Weekday napping was significantly (negatively) correlated with vocabulary and auditory attention span, and weekday nighttime sleep was positively correlated with vocabulary. Nighttime sleep was also significantly negatively correlated with performance, such that those who slept less at night made more impulsive errors on a computerized go/no-go test.
Conclusions
Daytime napping is actually negatively correlated with neurocognitive function in preschoolers. Nighttime sleep appears to be more critical for development of cognitive performance. Cessation of napping may serve as a developmental milestone of brain maturation. Children who nap less do not appear to be sleep deprived, especially if they compensate with increased nighttime sleep. An alternative explanation is that children who sleep less at night are sleep deprived and require a nap. A randomized trial of nap restriction would be the next step in understanding the relationship between napping and neurocognitive performance.
doi:10.1097/DBP.0b013e318207ecc7
PMCID: PMC3095909  PMID: 21217402
childhood; attention; sleep; cognition; actigraphy; preschool
7.  The Effects of Iron and/or Zinc Supplementation on Maternal Reports of Sleep in Infants from Nepal and Zanzibar 
Background
There is some evidence that sleep patterns may be affected by iron deficiency anemia but the role of iron in sleep has not been tested in a randomized iron supplementation trial.
Objective
We investigated the effect of iron supplementation on maternal reports of sleep in infants in 2 randomized, placebo-controlled trials from Pemba Island, Zanzibar, and Nepal.
Design
In both studies, which had parallel designs and were carried out in years 2002 to 2003, infants received iron–folic acid with or without zinc daily for 12 months, and assessments of development were made every 3 months for the duration of the study. Eight hundred seventy-seven Pemban (12.5 ± 4.0 months old) and 567 Nepali (10.8 ± 4.0 months) infants participated. Maternal reports of sleep patterns (napping frequency and duration, nighttime sleep duration, frequency of night waking) were collected.
Results
Mean Hb concentration was 9.2 ± 1.1 for Pemban and 10.1 ± 1.2 g/dL for Nepali infants. Approximately, one-third of the children were stunted. Supplemental iron was consistently associated with longer night and total sleep duration. The effects of zinc supplementation also included longer sleep duration.
Conclusions
Micronutrient supplementation in infants at high risk for iron deficiency and iron deficiency anemia was related to increased night sleep duration and less night waking.
doi:10.1097/DBP.0b013e31819e6a48
PMCID: PMC2771202  PMID: 19322104
infants; sleep; iron deficiency anemia; iron supplementation; developing countries
8.  Sleep disorders in children 
Clinical Evidence  2007;2007:2304.
Introduction
Sleep disorders may affect 20-30% of young children, and include excessive daytime sleepiness, problems getting to sleep (dysomnias), or undesirable phenomena during sleep (parasomnias), such as sleep terrors, and sleepwalking. Children with physical or learning disabilities are at increased risk of sleep disorders.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatments for dysomnias in children? What are the effects of treatments for parasomnias in children? We searched: Medline, Embase, The Cochrane Library and other important databases up to September 2006 (BMJ Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 14 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review we present information relating to the effectiveness and safety of the following interventions: antihistamines, behavioural therapy plus benzodiazepines, or plus chloral and derivates, exercise, extinction and graduated extinction, light therapy, melatonin, safety/protective interventions for parasomnias, scheduled waking (for parasomnias), sleep hygiene, and sleep restriction.
Key Points
Sleep disorders may affect 20-30% of young children, and include excessive daytime sleepiness, problems getting to sleep (dysomnias), or undesirable phenomena during sleep (parasomnias), such as sleep terrors, and sleepwalking. Children with physical or learning disabilities are at increased risk of sleep disorders. Other risk factors include the child being the first born, having a difficult temperament or having had colic, and increased maternal responsiveness.
There is a paucity of evidence about effective treatments for sleep disorders in children, especially parasomnias, but behavioural interventions may be the best first-line approach.
Extinction and graduated extinction interventions improve settling and reduce night wakes compared with placebo in healthy children, and in children with learning disabilities. Graduated extinction may be less distressing for parents, and therefore may have better compliance.Sleep hygiene interventions may reduce bedtime tantrums in healthy children compared with placebo, with similar effectiveness to graduated extinction.Sleep hygiene plus graduated extinction may reduce bedtime tantrums in children with physical or learning disabilities.We don't know whether combining behavioural therapy with benzodiazepines or with chloral improves sleep or parasomnias.
Melatonin may improve sleep onset and sleep time compared with placebo in healthy children, but we don't know if it is beneficial in children with disabilities, if it improves parasomnias, or what its long-term effects might be. We don't know whether antihistamines, exercise, light therapy, or sleep restriction improve dysomnias or parasomnias in children.We don't know whether safety or protective interventions, scheduled waking, extinction, or sleep hygiene are effective in children with parasomnias.
PMCID: PMC2943792  PMID: 19450298
9.  Use of Sleep Aids During the First Year of Life 
Pediatrics  2002;109(4):594-601.
Objective.
In an attempt to foster self-soothing during the night, a novel sleep aid infused with maternal odor was introduced to 4 groups of infants ranging in age from 3 to 12 months. Infants’ use of parent-provided sleep aids also was examined.
Methodology.
Nighttime sleep and waking behaviors were videotaped for 2 consecutive nights on 3 occasions over a 3-month interval. Using all-night video recording, the study examined the infant’s use of a novel sleep aid and parent-provided sleep aids during sleep onset and after nighttime awakenings.
Results.
Results indicated that infants of different ages differed in the types of sleep aids used when falling asleep either at the beginning of the night or after awakenings in the middle of the night. More 3-month-olds used their thumbs/fingers/hands, whereas more 6-month-olds used soft objects. The 6-month-olds were most likely to use the novel sleep aid. Almost all of the infants at all 4 ages used some type of object during the night. Intra-individual analyses showed that infants tended to change their pattern of sleep aid use over the 3-month study period.
Conclusions.
The data provide evidence that infants during the first year of life use sleep aids frequently and interchangeably rather than a specific favorite object.
PMCID: PMC1351014  PMID: 11927702
10.  Sleep disorders in children 
Clinical Evidence  2010;2010:2304.
Introduction
Sleep disorders may affect between 20% and 30% of young children, and include problems getting to sleep (dyssomnias), or undesirable phenomena during sleep (parasomnias), such as sleep terrors and sleepwalking. Children with physical or learning disabilities are at increased risk of sleep disorders.
Methods and outcomes
We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of treatments for dyssomnias in children? What are the effects of treatments for parasomnias in children? We searched: Medline, Embase, The Cochrane Library, and other important databases up to September 2009 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).
Results
We found 28 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.
Conclusions
In this systematic review we present information relating to the effectiveness and safety of the following interventions: antihistamines; behavioural therapy plus antihistamines, plus benzodiazepines, or plus chloral and derivatives; benzodiazepines alone; exercise; extinction and graduated extinction; 5-hydroxytryptophan; light therapy; melatonin; safety/protective interventions for parasomnias; scheduled waking (for parasomnias); sleep hygiene; and sleep restriction.
Key Points
Sleep disorders may affect between 20% and 30% of young children, and include problems getting to sleep (dyssomnias) or undesirable phenomena during sleep (parasomnias), such as sleep terrors and sleepwalking. Children with physical or learning disabilities are at increased risk of sleep disorders. Other risk factors include the child being the first born, having a difficult temperament or having had colic, and increased maternal responsiveness.
There is a paucity of evidence about effective treatments for sleep disorders in children, especially parasomnias, but behavioural interventions may be the best first-line approach.
Extinction and graduated extinction in otherwise healthy children with dyssomnia may improve sleep quality and settling, and reduce the number of tantrums and wakenings compared with no treatment. Extinction and graduated extinction in children with physical disabilities, learning disabilities, epilepsy, or attention-deficit disorder with dyssomnia may be more effective at improving settling, reducing the frequency and duration of night wakings, and improving parental sleep compared with no treatment; however, we don't know whether it is more effective in improving sleep duration.Graduated extinction may be less distressing for parents, and therefore may have better compliance.
Sleep hygiene for dyssomnia in otherwise healthy children may be more effective in reducing the number and duration of bedtime tantrums compared with placebo, but we don’t know if it is more effective at reducing night wakenings, improving sleep latency, improving total sleep duration, or improving maternal mood. Sleep hygiene and graduated extinction seem to be equally effective at reducing bedtime tantrums in otherwise healthy children with dyssomnia.We don't know whether sleep hygiene for dyssomnia in children with physical disabilities, learning disabilities, epilepsy, or attention-deficit disorder is effective.
Melatonin for dyssomnia in otherwise healthy children may be more effective at improving sleep-onset time, total sleep time, and general health compared with placebo. Evidence of improvements in dyssomnia with melatonin is slightly stronger in children with physical disabilities, learning disabilities, epilepsy, or attention-deficit disorder.
Little is known about the long-term effects of melatonin, and the quality of the product purchased could be variable as melatonin is classified as a food supplement.
Antihistamines for dyssomnia may be more effective than placebo at reducing night wakenings and decreasing sleep latency, but we don’t know if they are more effective at increasing sleep duration. The evidence for antihistamines in dyssomnia comes from only one small, short-term study.
We don’t know whether behavioural therapy plus antihistamines, plus benzodiazepines, or plus chloral and derivatives, exercise, light therapy, or sleep restriction are effective in children with dyssomnia.
We don’t know whether antihistamines, behavioural therapy plus benzodiazepines or plus chloral and derivatives, benzodiazepines, 5-hydroxytryptophan, melatonin, safety/protective interventions, scheduled waking, sleep hygiene, or sleep restriction are effective in children with parasomnia.
PMCID: PMC3217667  PMID: 21418676
11.  Sleep and Attachment in Preterm Infants 
Infant mental health journal  2013;34(1):37-46.
Infants born preterm are at elevated risk for social emotional difficulties. However, factors contributing to this risk are largely understudied. Within the present study, we explored infant sleep as a biosocial factor that may play a role in infant social emotional development. Within a prospective longitudinal design, we examined parent-reported sleep patterns and observed parenting quality as predictors of infant-mother attachment in 171 infants born preterm. Using structural equation modeling, we examined main effect and moderator models linking infant sleep patterns and parenting with attachment security. Sleep patterns characterized by more daytime sleep and positive/responsive parenting predicted infant attachment security. Parent-reported nighttime sleep patterns were unrelated to attachment in this sample of infants born preterm. These results indicate that daytime sleep and parenting quality may be important for emerging attachment relationships in infants born preterm.
doi:10.1002/imhj.21374
PMCID: PMC3590002  PMID: 23482430
sleep; attachment; preterm
12.  First Steps for Mommy and Me: A Pilot Intervention to Improve Nutrition and Physical Activity Behaviors of Postpartum Mothers and Their Infants 
Maternal and child health journal  2011;15(8):1217-1227.
To assess the feasibility of a pediatric primary care based intervention to promote healthful behaviors among 0–6 month old infants and their mothers. We enrolled two intervention practices (60 mother-infant pairs) and one usual care control practice (24 pairs) in a non-randomized controlled trial. We completed visits and interviews with 80 (95%) pairs at birth and 6 months. The intervention included (1) brief focused negotiation by pediatricians, (2) motivational counseling by a health educator, and (3) group parenting workshops. We evaluated the intervention effects on infant feeding, sleep duration, TV viewing, and mothers’ responsiveness to satiety cues. Maternal behavioral targets included postpartum diet, physical activity, TV and sleep. At 6 months, fewer intervention than control infants had been introduced to solid foods (57% vs. 82%; P = 0.04), and intervention infants viewed less TV (mean 1.2 vs. 1.5 h/d; P = 0.07). Compared to control infants, intervention infants had larger increases in their nocturnal sleep duration from baseline to follow up (mean increase 1.9 vs. 1.3 h/d; P = 0.05); larger reductions in settling time (mean reduction −0.70 vs. −0.10 h/d; P = 0.02); and larger reductions in hours/day of nighttime wakefulness (mean reduction −2.9 vs. −1.5 h/d; P = 0.08). There were no differences in breastfeeding, response to satiety cues, or maternal health behaviors. A program of brief focused negotiation by pediatricians, individual coaching by health educators using motivational interviewing, and group parenting workshops tended to improve infant feeding, sleep and media exposure, but had less impact on mothers’ own health-related behaviors.
doi:10.1007/s10995-010-0696-2
PMCID: PMC3219434  PMID: 20957514
Postpartum women; Infancy; Nutrition; Physical activity; Obesity prevention
13.  Eye of the beholder? Maternal mental health and the quality of infant sleep 
Transactional models of parenting and infant sleep call attention to bidirectional associations among parenting, the biosocial environment, and infant sleep behaviors. Although night waking and bedtime fussing are normative during infancy and early childhood, they can be challenging for parents. The current study, conducted in the United States between 2003 and 2009, examined concurrent and longitudinal associations between maternal mental health and infant sleep during the first year. Concurrent associations at 6 and 12 months and longitudinal associations from 6 to 12 months were studied in a non-clinic referred sample of 171 economically and culturally diverse families. Mothers with poorer mental health reported that their infants had more night waking and bedtime distress and were more bothered by these sleep issues. Associations between infant sleep and maternal mental health were moderated by culture (Hispanic/Asian vs. other) and by stressors that included high parenting stress, more stressful life events, and low family income. Individual differences in maternal well-being may color mothers’ interpretations of infants’ sleep behaviors. It may be prudent to intervene to support maternal mental health when infants are referred for sleep problems.
doi:10.1016/j.socscimed.2012.07.006
PMCID: PMC3540198  PMID: 22858167
night waking; infancy; sleep problems; depressive symptoms; anxiety; United States; mothers; ethnicity
14.  The Intervention Nurses Start Infants Growing on Healthy Trajectories (INSIGHT) study 
BMC Pediatrics  2014;14:184.
Background
Because early life growth has long-lasting metabolic and behavioral consequences, intervention during this period of developmental plasticity may alter long-term obesity risk. While modifiable factors during infancy have been identified, until recently, preventive interventions had not been tested. The Intervention Nurses Starting Infants Growing on Healthy Trajectories (INSIGHT). Study is a longitudinal, randomized, controlled trial evaluating a responsive parenting intervention designed for the primary prevention of obesity. This “parenting” intervention is being compared with a home safety control among first-born infants and their parents. INSIGHT’s central hypothesis is that responsive parenting and specifically responsive feeding promotes self-regulation and shared parent–child responsibility for feeding, reducing subsequent risk for overeating and overweight.
Methods/Design
316 first-time mothers and their full-term newborns were enrolled from one maternity ward. Two weeks following delivery, dyads were randomly assigned to the “parenting” or “safety” groups. Subsequently, research nurses conduct study visits for both groups consisting of home visits at infant age 3–4, 16, 28, and 40 weeks, followed by annual clinic-based visits at 1, 2, and 3 years. Both groups receive intervention components framed around four behavior states: Sleeping, Fussy, Alert and Calm, and Drowsy. The main study outcome is BMI z-score at age 3 years; additional outcomes include those related to patterns of infant weight gain, infant sleep hygiene and duration, maternal responsiveness and soothing strategies for infant/toddler distress and fussiness, maternal feeding style and infant dietary content and physical activity. Maternal outcomes related to weight status, diet, mental health, and parenting sense of competence are being collected. Infant temperament will be explored as a moderator of parenting effects, and blood is collected to obtain genetic predictors of weight status. Finally, second-born siblings of INSIGHT participants will be enrolled in an observation-only study to explore parenting differences between siblings, their effect on weight outcomes, and carryover effects of INSIGHT interventions to subsequent siblings.
Discussion
With increasing evidence suggesting the importance of early life experiences on long-term health trajectories, the INSIGHT trial has the ability to inform future obesity prevention efforts in clinical settings.
Trial registration
NCT01167270. Registered 21 July 2010.
doi:10.1186/1471-2431-14-184
PMCID: PMC4105401  PMID: 25037579
Obesity; Prevention; Infancy; Responsiveness; Home visitation; Feeding; Parenting
15.  Coparenting Quality During the First Three Months After Birth: The Role of Infant Sleep Quality 
The transition to parenthood can be stressful for new parents, as parents must learn to take on new roles and responsibilities. Sleep disruption—which has been linked in prior research to parent distress and fatigue—is common in the early months. The current study is the first to our knowledge to examine infant sleep and its potential indirect influence on parents’ perceptions of coparenting quality at 1 and 3 months of infant age. Participants included 150 families. Mothers reported more night waking, poorer sleep quality, more depressive symptoms, and worse perceptions of coparenting quality as compared with fathers. We tested a structural model of infant and parent night waking and sleep quality as predictors of parent distress and coparenting using maximum likelihood estimation. The frequency of infant night waking predicted father and mother night waking, which in turn predicted parent sleep quality. Poor parent sleep quality predicted elevated depressive symptoms, and finally depressive symptoms were negatively related to perceptions of coparenting quality. Significant indirect effects between infant night waking and parent depression and coparenting quality were found. In summary, both mothers’ and fathers’ perceptions of coparenting were related to the unfolding parental dynamics that take place surrounding infant sleep difficulties. This held true even after controlling for parent education, family income, and infant temperament. Therefore, parenting may indirectly benefit from interventions targeting infant sleep difficulties.
doi:10.1037/a0030707
PMCID: PMC3562740  PMID: 23244456
Transition to parenthood; coparenting; parent sleep; infant sleep; depression
16.  Nighttime Parenting Strategies and Sleep-Related Risks to Infants 
A large social science and public health literature addresses infant sleep safety, with implications for infant mortality in the context of accidental deaths and Sudden Infant Death Syndrome (SIDS). As part of risk reduction campaigns in the USA, parents are encouraged to place infants supine and to alter infant bedding and elements of the sleep environment, and are discouraged from allowing infants to sleep unsupervised, from bed-sharing either at all or under specific circumstances, or from sofa-sharing. These recommendations are based on findings from large-scale epidemiological studies that generate odds ratios or relative risk statistics for various practices; however, detailed behavioural data on nighttime parenting and infant sleep environments are limited. To address this issue, this paper presents and discusses the implications of four case studies based on overnight observations conducted with first-time mothers and their four-month old infants. These case studies were collected at the Mother-Baby Behavioral Sleep Lab at the University of Notre Dame USA between September 2002 and June 2004.Each case study provides a detailed description based on video analysis of sleep-related risks observed while mother-infant dyads spent the night in a sleep lab. The case studies provide examples of mothers engaged in the strategic management of nighttime parenting for whom sleep-related risks to infants arose as a result of these strategies. Although risk reduction guidelines focus on eliminating potentially risky infant sleep practices as if the probability of death from each were equal, the majority of instances in which these occur are unlikely to result in infant mortality. Therefore, we hypothesise that mothers assess potential costs and benefits within margins of risk which are not acknowledged by risk-reduction campaigns. Exploring why mothers might choose to manage sleep and nighttime parenting in ways that appear to increase potential risks to infants may help illuminate how risks occur for individual infants.
doi:10.1016/j.socscimed.2012.05.043
PMCID: PMC3505270  PMID: 22818487
infant sleep; sleep-related risks; Sudden Infant Death Syndrome (SIDS); nighttime parenting; USA
17.  Night Waking, Sleep-Wake Organization, and Self-Soothing in the First Year of Life 
Few objective data are available regarding infants’ night waking behaviors and the development of self-soothing during the first year of life. This cross-sectional study examined 80 infants in one of four age groups (3, 6, 9, or 12 mo) for four nights by using videosomnography to code nighttime awakenings and parent-child interactions. A large degree of variability was observed in parents’ putting the infant to bed awake or asleep and in responding to vocalizations after nighttime awakenings. Most infants woke during the night at all ages observed. Younger infants tended to require parental intervention at night to return to sleep, whereas older infants exhibited a greater proportion of self-soothing after nighttime awakenings. However, even in the 12-month-old group, 50% of infants typically required parental intervention to get back to sleep after waking. Results emphasize the individual and contextual factors that effect the development of self-soothing behavior during the first year of life.
PMCID: PMC1201414  PMID: 11530895
18.  Effects of Filtering Visual Short Wavelengths During Nocturnal Shiftwork on Sleep and Performance 
Chronobiology International  2013;30(8):951-962.
Circadian phase resetting is sensitive to visual short wavelengths (450–480 nm). Selectively filtering this range of wavelengths may reduce circadian misalignment and sleep impairment during irregular light-dark schedules associated with shiftwork. We examined the effects of filtering short wavelengths (<480 nm) during night shifts on sleep and performance in nine nurses (five females and four males; mean age ± SD: 31.3 ± 4.6 yrs). Participants were randomized to receive filtered light (intervention) or standard indoor light (baseline) on night shifts. Nighttime sleep after two night shifts and daytime sleep in between two night shifts was assessed by polysomnography (PSG). In addition, salivary melatonin levels and alertness were assessed every 2 h on the first night shift of each study period and on the middle night of a run of three night shifts in each study period. Sleep and performance under baseline and intervention conditions were compared with daytime performance on the seventh day shift, and nighttime sleep following the seventh daytime shift (comparator). On the baseline night PSG, total sleep time (TST) (p < 0.01) and sleep efficiency (p = 0.01) were significantly decreased and intervening wake times (wake after sleep onset [WASO]) (p = 0.04) were significantly increased in relation to the comparator night sleep. In contrast, under intervention, TST was increased by a mean of 40 min compared with baseline, WASO was reduced and sleep efficiency was increased to levels similar to the comparator night. Daytime sleep was significantly impaired under both baseline and intervention conditions. Salivary melatonin levels were significantly higher on the first (p < 0.05) and middle (p < 0.01) night shifts under intervention compared with baseline. Subjective sleepiness increased throughout the night under both conditions (p < 0.01). However, reaction time and throughput on vigilance tests were similar to daytime performance under intervention but impaired under baseline on the first night shift. By the middle night shift, the difference in performance was no longer significant between day shift and either of the two night shift conditions, suggesting some adaptation to the night shift had occurred under baseline conditions. These results suggest that both daytime and nighttime sleep are adversely affected in rotating-shift workers and that filtering short wavelengths may be an approach to reduce sleep disruption and improve performance in rotating-shift workers. (Author correspondence: casper@lunenfeld.ca)
doi:10.3109/07420528.2013.789894
PMCID: PMC3786545  PMID: 23834705
Melatonin; shiftwork; short-wavelength light; sleep efficiency; total sleep time; wake after sleep onset
19.  Temporal daily associations between pain and sleep in adolescents with chronic pain versus healthy adolescents 
Pain  2010;151(1):220-225.
Adolescents with chronic pain frequently report sleep disturbances, particularly short sleep duration, night wakings, and poor sleep quality. Prior research has been limited by assessment of subjectively reported sleep only and lack of data on daily relationships between sleep and pain. The current study utilized multilevel modeling to compare daily associations between sleep and pain in adolescents with chronic pain and healthy adolescents. Ninety-seven adolescents (n=39 chronic pain; n=58 healthy) aged 12–18, 70.1% female participated. Adolescents completed pain diary ratings (0–10 NRS) and actigraphic sleep monitoring for 10 days. Actigraphic sleep variables (duration, efficiency, WASO) and self-reported sleep quality were tested as predictors of next-day pain, and daytime pain was tested as a predictor of sleep that night. Effects of age, gender, study group, and depressive symptoms on daily associations between sleep and pain were also tested. Multivariate analyses revealed that nighttime sleep (p<.001) and minutes awake after sleep onset (WASO) (p<.05) predicted next-day pain, with longer sleep duration and higher WASO associated with higher pain. Contrary to hypotheses, neither nighttime sleep quality nor sleep efficiency predicted pain the following day. The interaction between nighttime sleep efficiency and study group was significant, with adolescents with pain showing stronger associations between sleep efficiency and next day pain than healthy participants (p=.05). Contrary to hypotheses, daytime pain did not predict nighttime sleep. Daily associations between pain and sleep suggest that further work is needed to identify specific adolescent sleep behaviors (e.g., compensatory sleep behaviors) that may be targeted in interventions.
doi:10.1016/j.pain.2010.07.016
PMCID: PMC2939216  PMID: 20719433
pain; chronic pain; actigraphy; adolescents; sleep; multilevel-modeling
20.  Adverse effects of parental smoking during pregnancy in urban and rural areas 
Background
Parental smoking during pregnancy is associated with lower birthweight and gestational age, as well as with the risks of low birthweight (LBW) and preterm birth. The present study aims to assess the association of parental smoking during pregnancy with birth outcomes in urban and rural areas.
Methods
This was a secondary analysis of data collected in the Indonesia Family Life Survey, between 1993 and 2007, the first national prospective longitudinal cohort study in Indonesia. Retrospective data of parental smoking habits, socioeconomic status, pregnancy history and birth outcomes were collected from parents with children aged 0 to 5 years (n = 3789). We assessed the relationships between the amount of parental smoking during pregnancy with birthweight (LBW) and with gestational age (preterm birth).
Results
We found a significant reduction in birthweight to be associated with maternal smoking. Smoking (except for paternal smoking) was associated with a decrease in the gestational age and an increased risk of preterm birth. Different associations were found in urban area, infants born to smoking fathers and both smoking parents (>20 cigarettes/day for both cases) had a significant reduction in birthweight and gestational age as well as an increased risk of LBW and preterm birth.
Conclusions
Residence was found to be an effect modifier of the relation between parental smoking during pregnancy, amount of parental smoking, and birth outcomes on their children. Smoking cessation/reduction and smoking intervention program should be advised and prioritized to the area that is more prone to the adverse birth outcomes.
doi:10.1186/s12884-014-0414-y
PMCID: PMC4302514  PMID: 25551278
21.  Sleep Patterns and Fatigue in New Mothers and Fathers 
Biological research for nursing  2004;5(4):311-318.
The purpose of this study was to describe the sleep patterns and fatigue of both mothers and fathers before and after childbirth. The authors used wrist actigraphy and questionnaires to estimate sleep and fatigue in 72 couples during their last month of pregnancy and 1st month postpartum. Both parents experienced more sleep disruption at night during the postpartum period as compared to the last month of pregnancy. Compared to fathers, with their stable 24-h sleep patterns over time, mothers had less sleep at night and more sleep during the day after the baby was born. Sleep patterns were also related to parents’work status and type of infant feeding. Both parents self-reported more sleep disturbance and fatigue during the 1st month postpartum than during pregnancy. Mothers reported more sleep disturbance than fathers, but there was no gender difference in ratings of fatigue. At both time points, fathers obtained less total sleep than mothers when sleep was objectively measured throughout the entire 24-h day. Further research is needed to determine the duration of sleep loss for both mothers and fathers, to evaluate the effect of disrupted sleep and sleep loss on psychosocial functioning and job performance, and to develop interventions for improving sleep patterns of new parents.
doi:10.1177/1099800403262142
PMCID: PMC1307172  PMID: 15068660
sleep; fatigue; mothers; fathers; pregnancy; postpartum; naps
22.  Symptomatic Dengue Infection during Pregnancy and Infant Outcomes: A Retrospective Cohort Study 
Background
Dengue is a mosquito-borne disease that is common in many tropical and subtropical areas. Dengue infections can occur at any age and time in the lifespan, including during pregnancy. Few large scale studies have been conducted to determine the risk of preterm birth (PTB) and low birthweight (LBW) for infants born to women who had symptomatic dengue infection during pregnancy.
Methodology/Principal Findings
This study is a retrospective cohort study using medical records from 1992–2010 from pregnant women who attended a public regional referral hospital in western French Guiana. Exposed pregnancies were those with laboratory confirmed cases of dengue fever during pregnancy. Each of the 86 exposed infants was matched to the three unexposed births that immediately followed them to form a stratum. Conditional logistic regression was used to analyze these matched strata. Three groups were examined: all infants regardless of gestational age, only infants> = 17 weeks of gestational age and their strata, and only infants> = 22 weeks of age and their strata. Odds ratios were adjusted (aOR) for maternal age, maternal ethnicity, maternal gravidity, interpregnancy interval and maternal anemia. There was an increased risk of PTB among women with symptomatic dengue; (aOR all infants: 3.34 (1.13, 9.89), aOR 17 weeks: 1.89 (0.61, 5.87), aOR 22 weeks: 1.41 (0.39, 5.20)) but this risk was only statistically significant when all infants were examined (p value = 0.03). Adjusted results for LBW were similar, with an increased risk in the exposed group (aOR All infants: 2.23 (1.01, 4.90), aOR 17 weeks: 1.67 (0.71, 3.93), aOR 22 weeks: 1.43 (0.56, 3.70)) which was only statistically significant when all infants were examined (p value = 0.05).
Conclusions/Significance
Symptomatic dengue infection during pregnancy may increase the risk of PTB and LBW for infants. More research is needed to confirm these results and to examine the role of dengue fever in miscarriage.
Author Summary
Previous studies have reported that dengue fever during pregnancy may be related to preterm birth and low birthweight among infants. However, few studies have used an appropriate control group to compare the risk of these outcomes for infants whose mothers had dengue fever to infants whose mothers did not. We designed this study to provide information on the amount of risk (odds ratios) and the stability of this risk (confidence intervals) of being born preterm or with low birthweight to a mother with documented dengue infection during the pregnancy. In this study there was an increased risk among pregnant women with symptomatic dengue to deliver infants who are preterm or low birthweight, but both the amount of risk and the stability of this risk were affected by the inclusion or exclusion of miscarriages (infants born before 22 weeks of gestational age) This suggests that women who are pregnant should take extra precautions to avoid dengue infections during pregnancy, since it may cause an early delivery, or the birth of a small infant.
doi:10.1371/journal.pntd.0003226
PMCID: PMC4191958  PMID: 25299383
23.  The Origins of 12-Month Attachment: A Microanalysis of 4-Month Mother-Infant Interaction 
Attachment & human development  2010;12(0):3-141.
A detailed microanalysis of 4-month mother-infant face-to-face communication revealed a fine-grained specification of essential communication processes that predicted 12-month insecure attachment outcomes, particularly resistant and disorganized classifications. An urban community sample of 84 dyads were videotaped at 4 months during a face-to-face interaction, and at 12 months during the Ainsworth Strange Situation. Four-month mother and infant communication modalities of attention, affect, touch, and spatial orientation were coded from split-screen videotape on a 1s time base; mother and infant facial-visual “engagement” variables were constructed. We used contingency measures (multi-level time-series modeling) to examine the dyadic temporal process over time, and specific rates of qualitative features of behavior to examine the content of behavior. Self-contingency (auto-correlation) measured the degree of stability/lability within an individual’s own rhythms of behavior; interactive contingency (lagged cross-correlation) measured adjustments of the individual’s behavior that were correlated with the partner’s previous behavior.
We documented that both self- and interactive contingency, as well as specific qualitative features, of mother and infant behavior were mechanisms of attachment formation by 4 months, distinguishing 12-month insecure, resistant, and disorganized attachment classifications from secure; avoidant were too few to test. All communication modalities made unique contributions. The separate analysis of different communication modalities identified intermodal discrepancies or conflict, both intrapersonal and interpersonal, that characterized insecure dyads. Contrary to dominant theories in the literature on face-to-face interaction, measures of maternal contingent coordination with infant yielded the fewest associations with 12-month attachment, whereas mother and infant self-contingency, and infant contingent coordination with mother, yielded comparable numbers of findings. Rather than the more usual hypothesis that more contingency is “better,” we partially supported our hypothesis that 12-month insecurity is associated with both higher and lower 4-month self- and interactive contingency values than secure, as a function of mother vs. infant and communication modality. Thus, in the origins of attachment security, more contingency is not necessarily better.
A remarkable degree of differentiation was identified in the 4-month patterns of “future” C and D infants, classified as resistant and disorganized, respectively, at 12 months. Only future D infants were emotionally distressed, with simultaneous positive and negative discrepant affect; only their mothers showed difficulty in sharing infant affect, particularly distress, and lowered their contingent coordination with infant facial-visual engagement. This lowered contingent coordination makes it more difficult for infants to come to expect that their emotional/attentional states can influence mothers to coordinate with them and thus compromises the infant’s sense of interactive efficacy. Only future C dyads showed the spatial approach/avoid pattern of “chase and dodge;” only mothers of future D infants showed the spatial intrusion pattern of “looming” into the infant’s face. Both future C and D dyads showed patterns of touch dysregulation. Future C infants inhibited their emotional coordination with mothers’ less affectionate touch, as if tuning it out. Future D dyads showed a dyadic touch dysregulation, in which mothers lowered their coordination with infant touch, while infants had a lowered ability to use their own touch. Both mothers of future C and D infants disturbed the stability of the spatial “frame” of the encounter by transitioning among upward, forward and loom orientations in less predictable ways than mothers of future B infants. Only mothers of future D infants disturbed the attentional “frame” as well, by looking and looking away from the infant’s face in less predictable ways than mothers of future B infants. Only mothers of future D infants showed methods of managing their own state which distanced them from their infants, such as extensive looking away and “closing up” their faces.
The intact interactive contingency of the mother of the future C infant overall safeguards the infant’s interactive agency, and the infant’s expectation that mother will match the direction of infant affective change, sharing infant states. However, we proposed that the future C infant will have difficulty feeling sensed and known by mother during her spatial/tactile intrusions.
The central feature of future D dyads is intrapersonal and interpersonal discordance or conflict in the context of intensely distressed infants. Lowered maternal contingent coordination, and failures of maternal affective correspondence, constitute maternal emotional withdrawal from distressed infants, compromising infant interactive agency and emotional coherence. The level of dysregulation in future D dyads is thus of an entirely different order than that of future C dyads. We proposed that the future D infant represents not being sensed and known by the mother, particularly in states of distress. We proposed that the emerging internal working model of future D infants includes confusion about their own basic emotional organization, about their mothers’ emotional organization, and about their mothers’ response to their distress, setting a trajectory in development which may disturb the fundamental integration of the person.
The findings have rich implications for clinical intervention, with remarkable specificity for different kinds of mother and infant distress. The concepts of heightened and lowered self- and interactive contingency, in different modalities, as well as the specific behavioral qualities identified, provide a more differentiated set of concepts to guide clinical intervention.
doi:10.1080/14616730903338985
PMCID: PMC3763737  PMID: 20390524
24.  Prevalence, Patterns, and Persistence of Sleep Problems in the First 3 Years of Life 
Pediatrics  2012;129(2):e276-e284.
OBJECTIVE:
Examine the prevalence, patterns, and persistence of parent-reported sleep problems during the first 3 years of life.
METHODS:
Three hundred fifty-nine mother/child pairs participated in a prospective birth cohort study. Sleep questionnaires were administered to mothers when children were 6, 12, 24, and 36 months old. Sleep variables included parent response to a nonspecific query about the presence/absence of a sleep problem and 8 specific sleep outcome domains: sleep onset latency, sleep maintenance, 24-hour sleep duration, daytime sleep/naps, sleep location, restlessness/vocalization, nightmares/night terrors, and snoring.
RESULTS:
Prevalence of a parent-reported sleep problem was 10% at all assessment intervals. Night wakings and shorter sleep duration were associated with a parent-reported sleep problem during infancy and early toddlerhood (6–24 months), whereas nightmares and restless sleep emerged as associations with report of a sleep problem in later developmental periods (24–36 months). Prolonged sleep latency was associated with parent report of a sleep problem throughout the study period. In contrast, napping, sleep location, and snoring were not associated with parent-reported sleep problems. Twenty-one percent of children with sleep problems in infancy (compared with 6% of those without) had sleep problems in the third year of life.
CONCLUSIONS:
Ten percent of children are reported to have a sleep problem at any given point during early childhood, and these problems persist in a significant minority of children throughout early development. Parent response to a single-item nonspecific sleep query may overlook relevant sleep behaviors and symptoms associated with clinical morbidity.
doi:10.1542/peds.2011-0372
PMCID: PMC3357046  PMID: 22218837
sleep problems; infants; toddlers; prevalence; persistence
25.  Exploring Socioeconomic Differences in Bedtime Behaviours and Sleep Duration in English Preschool Children 
Infant and Child Development  2014;23(5):518-531.
Children's sleep is critical for optimal health and development; yet sleep duration has decreased in recent decades, and many children do not have adequate sleep. Certain sleep behaviours (‘sleep hygiene’) are commonly recommended, and there is some evidence that they are associated with longer nighttime sleep. Parents of 84 British 3-year-old children were interviewed about their children's sleep and completed five-night/four-day sleep diaries documenting their children's sleep, from which daily sleep duration was estimated. Diaries were validated by actigraphy in a subgroup of children. Sleep hygiene behaviours (regular bedtime, reading at bedtime, falling asleep in bed) were associated with each other, and were more common in the high socioeconomic status compared to the low socioeconomic status group. Parents' reasons for not practicing sleep hygiene included difficulty, inability or inconvenience. Sleep hygiene behaviours were associated with significantly longer child sleep at night but not over 24 h. Longer daytime napping compensated for shorter nighttime sleep in children whose parents did not implement sleep hygiene behaviours. Parents may need to be advised that certain behaviours are associated with longer nighttime sleep and given practical advice on how to implement these behaviours. © 2014 The Authors. Infant and Child Development published by John Wiley & Sons, Ltd.
doi:10.1002/icd.1848
PMCID: PMC4283760  PMID: 25598710
sleep; preschool children; sleep hygiene; England; mixed methods; anthropology

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