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Supporting sleepless families: evidence and best practice

Key learning points:

 - The effect lack of sleep has on children and families 

 - The public health consequences of sleeplessness

 - Assessment and prevention of sleep issues 

The Channel 4 Bedtime Live Programme aired earlier this year highlighted the nation's interest in sleep matters and the devastating effect lack of sleep has on children and families. It also showcases the pivotal role health visitors can play in working with families to support and resolve sleep issues. All practitioners working with families need an awareness of the effects that sleep deprivation can have on health and wellbeing.

At Netmums more than 8,000 parents a month access the sleep support pages and over 3,000 parents seek direct help with sleep issues. These figures represent the tip of an iceberg, reflected in a recent survey1 of over 11,000 parents with young children. Results showed 41% had some difficulties at bedtime and 55% had children waking in the night. Health visitors and online support were the most popular sources parents turned to.

This online survey reflects the international evidence on the frequency and prevalence of sleep issues.2-5 The Institute of Health Visiting (iHV) have launched a Sleep Well campaign6 to strengthen health visiting advice to parents suffering sleep difficulties. There is no national evidence-based guidance on managing infant sleeping difficulties, yet it is a serious public health issue. 

The effects of sleep deprivation

In the UK, sleep deprivation has been identified by the Mental Health Foundation7 as a major public health priority, yet it is given scant attention. 

Sleep and settling difficulties in under fives are common and cost the NHS millions of pounds annually. In 2001, a heath economist8 calculated the cost to the NHS at over £65 million in professional salaries alone, just dealing with infants under three months old. This is before any costs of employment, accidents, injuries, absenteeism, post-natal depression (PND), safeguarding issues and relationship breakdowns are factored in. Research shows that driver fatigue may be a contributory factor in up to 20% of road accidents, and up to one quarter of fatal and serious accidents.9,10 The Bedtime Live programme demonstrated that tired parents doing the school run were more dangerous than drivers who had been drinking. 

The effects of sleep deprivation on can seriously affect maternal mental health, mood and fatigue11 and may exacerbate post-natal depression leading to costly treatments and medication. There is a link with sleep and crying and shaken baby syndrome12  Sleep deprivation is serious for both parents and children as it increases the risk of serious and chronic health conditions, including depression, diabetes, heart disease and obesity.13 Lack of sleep has adverse behavioural effects leading to tiredness, irritability, anxiety, depression and aggression which can lead to increased risks of domestic and child abuse. These behaviours can significantly impact on family and work relationships. In the Netmums survey1 19% said their relationship had been affected. This reflects the research14 which shows that 37% of parents reported it caused serious arguments and 2% felt it was responsible for the break-up of their marriage. Add to this the effect sleep deprivation has on parenting capacity and how it can impact on bonding and you have a dangerous cocktail of risk factors. 

Children who are sleep deprived are often grumpy, irritable and often hyperactive. It affects their growth, health, development and immune system. It affects children's concentration, verbal creativity, abstract thinking and ability to learn. This has serious implications not only for the child who is sleep deprived but also for any siblings affected. It is vital that practitioners take sleep disturbances seriously and support families in resolving them. 

Normal sleep patterns 

It is vital that both practitioners and families have realistic expectations of normal sleep patterns in infants. The longest sleep period for infants in the first week of life is four hours, compared to over eight hours in the 16th week. Environmental as well as maturational effects influence this shift. Newborns have not yet developed their own internal circadian rhythms or the production of melatonin15 which helps regulate sleep and makes you sleepy. Cortisol has a natural circadian rhythm that regulates waking and keeps you alert.16 However this pattern does not develop until infants are several months old, and cortisol is what helps infants sleep at night and be awake during the day. In the early weeks sleep patterns are influenced by hunger, feeding, digesting and becoming hungry again which is roughly every two to three hours. 

Most babies don't develop strong, hormonally-driven circadian rhythms until they are twelve weeks old, and some babies may take considerably longer.17,18 Circadian rhythms help determine human sleep patterns and respond primarily to light and darkness in the environment. Light is the main cue influencing circadian rhythms which control patterns of sleep and waking, rest, activity, hunger, eating, hormones and fluctuations in body temperature.

Prevention of sleep issues 

The evidence suggests that social cues may have the greatest influence on newborn sleep patterns19 so helping newborns to adjust to daily routines and reducing light and stimulation at night is helpful. Although there is some controversy around the issues of self-soothing,20 infants who can self-soothe and self-regulate appear to be able to resettle themselves back to sleep without signalling or requiring adult intervention.21 Parents can support this by encouraging their baby to learn how to self-settle from birth onwards. 

When does a sleep or settling issue become a problem?

If the parent thinks sleep is a problem then it is an issue that needs to be talked though and support offered. Often it is a case of inappropriate expectations of how children sleep, and parents may require help to explore and reflect on this. What one parent thinks of as a sleep issue another parent may regard as normal; all of us wake regularly in the night during the light sleep phase. When babies cry when they wake, parents then become aware of these awakenings. The infant crying disturbs the parent's sleep - not the fact the baby is awake. Research22 has shown that fussing and crying during the night typically lasted one to three minutes. Parental concerns about infant night waking reflect Western cultural practices and norms that make it harder for parents to cope with being kept up at night. 

Richman23 developed criteria for classifying children's sleep problems and a modified version of this is commonly used by clinicians see below:

- Infant has been waking and crying five nights a week for over three months.

 - Waking three times a night or more.

 - Waking for twenty minutes a night or more.

 - Coming into parental bed as the infant will not sleep.

Many parents have reached breaking point long before the official recognition of a sleep problem has been recognised using the above criteria.

Assessment of sleep issues in practice

To help parents, effectively taking a history and making an accurate sleep assessment is crucial. Listening to parent's fears, worries and concerns is essential if you are going to be able to work with them using a partnership approach.24 Parents need to know and feel you have heard and understood them and be reassured this is a common issue and it is not a failing on their part, as many parents feel guilty or a failure. Feeling confident in your ability to help them and sharing with them your confidence in their ability to resolve this with your help is vital. 

Be mindful that prolonged crying is reported more frequently by depressed mothers and makes them more susceptible to broken nights and infant crying.21 Other vulnerabilities such as poor parent-infant attachment, low self-confidence in the mother and an inability to tolerate stress all need to be considered as well as the infant behaviour. Sleep issues can be considered under an environmental, behavioural or physical heading and possible causes examined. Box 1 explores some possible causes of sleep disturbance.

There are some areas you need to explore with the family so you can get a clear picture of what exactly is occurring so you can accurately identify what the issues are. If possible have both parents present, as they need to be able to agree and support one another with any planned intervention. Explain to parents why you need this information and complete the assessment together. A sleep assessment form and diary can be downloaded from the Netmums website (see Resources).25

Areas to explore during a sleep assessment: 

 - Information about the household.

 - Information about the baby/child and their behaviour.

 - Information about bedtime routines and settling behaviour.

- Information about the sleep issues and what the parent currently does.

- Information on what the family have tried already and their hopes, fears and priorities.

 - Any information that has not been covered in the above areas the practitioner can enquire about. Part of this sleep assessment process involves completing with the parents a 24-hour sleep diary based on the previous 24 hours to give a picture of what is currently happening. This also provides a baseline for monitoring future progress. Daytime naps, bedtime routines, feeding and the baby/child's ability to self-settle are key areas the practitioner needs to focus on.

The information from the history and sleep assessment will help to correctly identify what the settling and sleep issues are so the clinician can then work with the parent to devise an action plan based on this information.

Help parents to prioritise what to tackle first and break steps down into small steps they can achieve success this will help to build their confidence and self-efficacy. Once they have decided on their short-term and long-term aims together, consider what order they would like to work on these in and this will form the basis of the weekly action plans. Encourage parents to think about what help they may need in terms of resources or support to carry through what needs to be done. Help them to think through possible difficulties they may encounter and how they might deal with this.

Having explored the different sleep interventions parents can use allow then to choose the best option for them and their circumstances. It is really important to respect their parenting style, and parents need to feel comfortable with the sleep coaching progamme they choose, otherwise they will not be likely to stick to it. Calmness, consistency and persistence are vital to success.

It is helpful if you can write the plan of action down for parents so everyone is clear about what they are doing. SMARTER objectives are a useful tool in helping parents to formulate a plan and a helpful way of measuring progress. SMARTER stands for specific, measurable, achievable, realistic, time limited, evaluation and review. 

Keeping a weekly sleep diary26 will help them to stay on track and enable everyone to evaluate progress and deal with issues that occur. Ensure they have contact telephone number so they can get help if they need to before the next appointment. Knowing help is at hand if they need it gives parents confidence to tackle sleep and settling issues. Usually when supporting parents with a sleep coaching programme you need to have regular contact to review progress and the sleep diary. For parents who are really stressed, unsupported or struggling they may need to have a follow up call in the intervening week. Messages of support are important to encourage them and keep them motivated, and enable the practitioner to deal with any difficulties that arise. 

Stay positive and encouraging, find small amounts of progress to praise, focus on strengths and solutions and notice the efforts they are making. 

Conclusion

Understanding normal sleep patterns and the effects sleep deprivation has on children and families will enable practitioners to take seriously the concerns parents have. Often preventative advice in the early weeks and months can prevent may sleep and settling issues occurring. 

When difficulties do arise an effective sleep assessment done in partnership with the parents can help them to formulate an realistic action plan to resolve the sleep or settling issue. Community practitioners are in an ideal position to support and help sleep deprived families. 

 

References

1. Netmums National Sleep Week, Netmums sleep survey results, August 2012

2. Armstrong K, Quinn R, Dadds M. The sleep patterns of normal children. The Medical Journal of Australia 1994;161:202-6. 

3. Betramni A, Hertzig M. Sleep and bedtime behaviour in preschool aged children. Paediatrics 1983;71:153-8.

4. Galbraith L, Hewkitt K, Pritchard L. Behavioural treatment for sleep disturbance. Health Visitor 1993;66(5):169-71.

5. Scott G, Richards MPM. Night waking in infants: effects of providing advice and support for parents. Journal of Child Psychology and Psychiatry 1989;31:551-69. 

6. Institute of Health Visiting Sleep Well Campaign. 2013. Available at: www.ihv.org.uk/campaigns 

7. Robotham D, Chakkalackal L, Cyhlarova E. Sleep Matters: The Impact of Sleep of Sleep on Health and Well Being. London: The Mental Health Foundation; 2011.

8. Morris S, St James-Roberts L, Sleep J, Gillham P. Economic evaluation of strategies for managing infant crying and sleeping problems in the first 12 weeks of age: the COSI study. Archives of Disease in Childhood. 2001;84:15-14.

9. Horne J, Reyner L. Sleep Related Vehicle Accidents Sleep Research Laboratory at Loughborough University, 2000. 

10. Department for Transport's Road Safety Research Sleep-Related Crashes on Sections of Different Road Types in the UK, 1995-2001.October 2004, Report No. 52. 

11. Meltzer LJ, Mindell JA. Relationship between child sleep disturbances and maternal sleep, mood, and parenting stress: A pilot study. Journal of Family Psychology 2007;21(1):67-73. doi: 10.1037/0893-3200.21.1.67 

12. Barr RG, Trent RB, Cross J. Age-related incidence curve of hospitalized Shaken Baby Syndrome cases: convergent evidence for crying as a trigger to shaking. Child Abuse and Neglect 2006(1):7-16.

13. Stores G. Sleep problems in children and adolescents. Oxford: Oxford University Press; 2009.

14. Chavin W, Tinson C. Coping with Sleep Difficulties. Health Visitor 1980(53):477-80.

15. Kennaway D, Goble F, Stamp G. Factors influencing the development of melatonin rhythmicity in humans. Journal of Clinical Endocrinology & Metabolism 1996(81):1525-32. 

16. Rivkees S, Mayes L, Jacobs H, Gross I. Rest-activity patterns of premature infants are regulated by cycled lighting. Pediatrics 2004;113(4):833-9. 

17. Jenni OG, DeBoer T, and Acherman P. Development of the 24h rest-activity pattern in human infants. Infant behavior and development 2006;29:143-152. 

18. Jenni OG, Carskadon MA. Sleep Behavior and Sleep Regulation from Infancy through Adolescence: Normative Aspects Sleep Medicine Clinics 2007;2(3):321-9. 

19. Lohr B, Siegmund R. Ultradian and circadian rhythms of sleep-wake and food-intake behavior during early infancy. Chonobiology international 1999;16(2):129-48. 

20. Weinraub M, Bender R, Friedman S, Susman E, Knoke E, Bradley R, Houts R, Williams J. Patterns of Developmental Change in Infants' Nighttime Sleep Awakenings from 6 through 36 Months of Age. Developmental Psychology 2012;48(6):1511-28. 

21. St James-Roberts I. The Origins, Prevention and Treatment of Infant Crying and Sleeping Problems. London: Routledge; 2012. 

22. Keener M, Zeanah C, Anders T. Infant temperament, sleep organisation and nighttime parental interventions. Paediatrics 1988;81:762-71.

23. Richman N. A community survey of characteristics of one- to two-year-olds with sleep disruptions. Journal of American Academy of Child Psychiatry 1981;20:281-91.

24. Davis D, Day C, Bidmead C. Working in Partnership with Parents. London: The Psychological Corporation; 2002.

25. Netmums sleep assessment form to download 

26. Netmums sleep diary to downloa