Reducing Night Waking in Infancy: A Primary Care Intervention

PEDIATRICS

APl1S2:

vii. n:

W.4:

Reducing Night Waking in Infancy:

A

Primary

Care

Intervention

Robin Adair, MD*; Barry Zuckerman, MD*; Howard Bauchner, MD*;

Barbara Philipp,

MD§;

and Suzette Levenson, MPHt

ABSTRACT.

Approximately

25% of infants wake

regu-larly

at

night

and need

help

in

resettling. The

purpose

of this

study

was to

implement

and evaluate

a

brief

intervention

to prevent

such

night waking. The study

used

a

prospective

cohort

design with historical controls.

Information from the control

group was collected at the

9-month visit. The intervention

group was

enrolled

at

the 4-month visit. The intervention consisted of

infor-mation about

sleep-onset

associations, completion of

a

sleep chart, and discussion about

sleep

with the

pedia-tridan.

The

outcome was

also measured

at

the 9-month

visit.

To

obscure

the

purpose

of the

study,

the outcome

questionnaire for

both groups

addressed

feeding and

sleeping.

One hundred

twenty-eight

(74%) of

172

eligible

infant-parent pairs comprised the control

group

and

164

(74%) of

222

the intervention

group.

The majority of

families

were

white,

married, and well-educated.

The groups were

similar with

regard

to

sociodemographic

variables and factors

thought

to

be related

to

night

wak-ing such

as current

breast-feeding, thumb/pacifier

suck-ing,

maternal

isolation,

and

parental perception of

diffi-cult

child. At

9

months of

age,

the intervention

infants

were

reported

to

experience

36%

less

night waking

per

week

compared

with those in

the control group

(2.5

vs

3.9

wakings

per

week,

P=

.02). Frequent night waking

was

twice

as commonin

control infants

(27%

vs

14%,

P

=

.01).

It

is

concluded

that

this

pediatric intervention

can

help

parents

reduce

night

waking

in

infants. Pediatrics

1992;89:585-588; sleep problems, infants, primary

care

in-tervention,

anticipatory guidance

and

prevention.

Night waking

is

common

among young

children

and

frequently

causes

parental

sleeplessness

and

con-cern.

The

prevalence

of

regular night waking,

de-pending

how it is

defined,

has been

reported

to

be

between

10%

and

44%

in

infants

between

4

and 15

months of

age.'-6

Various

factors

have been

associ-Fromthe*DivisionofDevelopmental and Behavioral Pediatrics, Department ofPediatrics,BostonCity Hospital, BostonUniversity School ofMedicine, Boston, MA;tBostonUniversity School ofPublicHealth; and§Department of Pediatrics and AdolescentMedicine,LaheyClinicMedicalCenter, Bur-lington,MA.

Received forpublicationMar22, 1991;acceptedMay 15,1991.

Reprintrequests to(B.Z.)DivisionofDevelopmental and Behavioral Pedi-atrics,Dept ofPediatrics,BostonCity Hospital,Boston,MA 02118. PEDIATRICS(ISSN00314005).Copyright©)1992by theAmerican Acad-emyof Pediatrics.

ated

with

night waking

such as the

child's

tempera-ment,3'7

perinatal

problems,

8

maternal

employment,2

family

stress

and

depression,'9-1 breast-feeding,2'12'13

and inappropriate

sleep

behaviors.14

The management

of

frequent

night

waking has

received

attention in

the lay

press"5'

and in

profes-sional

publications.17-22

The most common

recom-mendation to

decrease night waking has been the

introduction

of consistent routines and systematic

rewards

for

bedtime behaviors, plus

counseling/sup-port.

17-19

It is

unclear whether written

information

alone

without counseling is

effective.20'21

Finally, one

uncontrolled study

suests

that

frequent

night

wak-ing can be

diminished

if a parent completes a

sleep

chart.

A

popular

book on sleep by

Ferber16

suggests

par-ents

contribute

inadvertently

to

night

waking

when

the

rock, hold,

and/or feed

their

infants

to

get them

to

sleep.

When this occurs, the

infant

establishes a

learned association between parental presence and

falling asleep. Consequently,

when the

infant

awak-ens, he or she

desires the same condition (parental

presence) in order to again

fall asleep. The association

between

parental

presence

when an

infant

is

falling

asleep

and later night waking requiring a parent's

presence was

demonstrated in the

first

phase

of

this

investigation.23

This model

of

sleep-onset

associations

contributing

to

parental

involvement with

their

child's

waking

at

night has

led to the untested

rec-ommendation that parents

put their

infant

to

bed

awake.

An

important

goal

of

pediatric

primary

care is to

provide

anticipatory

guidance

in

order to prevent

problems.

The aim

of this

study

is to

determine

whether a

brief anticipatory

guidance

intervention

would reduce parental involvement with night

wak-ing.

MATERIALS AND METHODS

Parents were consecutively recruited when they broughttheir infantstothe Lahey ClinicMedicalCenterinBurlington, Massa-chusetts. Toobscure fromparents the focus of the research, the study was presented as the

"Infant

Feeding and Sleep Habits

Study.'Thestudy usedaprospectivecohortdesign with historical controls. Control subjects were consecutively recruited between at Viet Nam:AAP Sponsored on September 1, 2020

www.aappublications.org/news

July

1988and December 1988atthe 9-month-old well-childvisit. After

signing

a consentform to

participate

inthe

study,

mothers wereaskedto

complete

a

questionnaire consisting

ofclosed-ended,

forced-choice

questions

eliciting

information about their infant's

feeding

and

sleeping

behaviors and the

demographic

and

psycho-social characteristicsof the

family.

Sincethe

questionnaire

required

approximately

30 minutes to

complete,

mothers were

given

stamped,

self-addressed

envelopes

inwhich to return

completed

questionnaires.

Intervention

subjects

were

consecutively

recruited between No-vember 1988 and June 1989 at the 4-month health

supervision

visit.The intervention consistedof(1)writteninformation

given

to

parentsatthe 4-monthwell-child visit

regarding sleep-onset

asso-ciations,

(2)

completion

ofa

sleep

chart

by

parents

prior

tothe 6-monthvisit,and

(3)

discussion of the

sleep

chart with the

pediatri-cianatthe6-monthwell-childvisit.Outcome informationfor data

analysis

was obtained from the same

questionnaire

from both groupsat9monthsof age..

At the 4-month health

supervision

visit, intervention mothers were

given

two sheets of information. The first sheet contained advice about

feeding

and the second about

sleep (available

from the

author).

The purpose of the information sheet about

feeding

wastoobscure the focusof the intervention. Parentswereadvised toputtheirinfantina

high

chairatmealtimeassoon astheinfant couldsit without support. The rationale for this advice was pro-vided. The information

regarding sleep

stated that their infant would soon be able

physiologically

to

forgo

night

feedings.

In

preparation

for this

change

the parents were advised to

begin

establishing

a bedtime routine that included

putting

their infant intothecrib

partially

awake,sothe child couldlearntogoto

sleep

withoutanadult

being

present.Atthe time theinformation sheets were

given

to parents, noverbalreinforcement was

provided by

the

pediatrician.

The second

phase

of the intervention consisted of a

Daily

RoutineChartthatwasmailedtotheparentswhen theinfantwas 5 monthsold. This chartwas an

adaptation

ofa

previously

used

chart22and included both

sleep

and

feeding

behavior. The instruc-tionstold parentsto notethe times when the child ate,

slept,

and cried

during

five consecutive

days.

During

the 6-monthvisit, the

parentsdiscussed the

Daily

RoutineChart with the

pediatrician.

Theoutcomesof interestat9monthswere

(1)

parental

presence at thetimetheinfant fell

asleep

atbedtime and

(2)

the

frequency

of

night waking during

the

preceding

seven

nights.

Information was

again

obtained

by questionnaire.

A parent was classified as

.present'

when thechildfell

asleep

if theparent wasinvolvedin

feeding, rocking, walking,

or

singing

the child to

sleep;

in

lying

down with thechild until heorshe

slept;

or

by simply being

inthe child'sroomatbedtime.

'Nighttime'

wasdefinedinthe

questionnaire

as1hourafter the child's bedtime until thestartof thenext

day. 'Night waking'

was defined as an

episode

of infant arousal

during

the

nighttime

that

required

the parent to resettle the child.

'Night

waking'

was evaluated as acontinuousvariable

(number

of

episodes)

andas a

categorical

variablelabeled

'frequent

night waking' (seven

ormore

night wakings

inthe

prior week).

Inadditionto

questions

regarding

sleep

behavior,parents were also asked a number of

questions

regarding

their child's

feeding

habits.

Examples

of these

questions

included: 'How does your child

usually

drinkfluids?' and 'How often is your child

placed

ina

high

chair at mealtime?' Other

questions

elicited whether the mother felt isolated and her

perception

of her child's difficultness with activitiesof

daily living.

Parentswereaskedtodescribe 10areasof their child's

functioning

(eg,

feeding,

settling

for naps,

responding

to

being disciplined)

as

'easy,' 'average,'

or 'difficult.' For the purpose of

analysis,

parental

perceptioni

of difficultnesswas de-fined as a score at or above the 90%

percentile

for this

study

population.

The

study

was

approved by

theHumanStudies Committee at the

Lahey

Clinic Medical Center. The Statistical

Package

for Social Scienceswasusedto

analyze

the data. Bivariate

analyses

usethe Student'st test tocompare themeansofcontinuousvariables,and thextestfor

dliscrete

data. All

reported

Pvaluesaretwo-tailed.

RESULTS

All

of

the 172 control

subject

parents

approached

agreed

to

participate

and

128

(74%)

completed

and

returned

the

questionnaire.

Of

the 225

potential

par-ents

eligible

for

the

intervention,

1

declined

to

partic-ipate

and

2

withdrew

after

enrolling.

Of

the 222

intervention

subjects,

164

(74%)

completed

and

re-turned

the

questionnaire

at

9

months.

To

determine

comparability

of

family backgrounds

between the intervention

and control

groups,

the

following demographic

factors

were

compared:

infant

age,

gender ethnicity,

birth

weight,

and

presence of

siblings,

and

parental

age,

education,

marital

status,

and median

family

income.

No

significant

differences

were

noted

(see

Table

1)

for any of these

factors,

except

for infant age

(9.4

vs

9.2

months).

In

addition,

there

were no

differences between

the

control and

intervention

groups

on

the

following

factors

thought

be be related

to

night waking:

current

breast-feeding

(19%

vs

16%,

P

=

.47);

thumb

or

pacifier

use

(62%

vs

64%,

P

=

.78);

maternal

self-report

of

isolation

(20%

vs

20%,

P

=

.94);

and

maternal

perception

of

a

difficult

child

(10%

vs

8%,

P

=

.65).

The intervention

infants

were

reported

to

experi-ence

36% less

night waking

than those in

the control

group

(P

=

.02;

Table

2).

Frequent

night waking

was

twice

as common

in

control infants

(P

= .

0

1).

The

mothers in

the

intervention

group

also

reported

that

their

infants

were

easier

to

settle

for

sleep,

both for

maps

(57%

vs

38%,

P

=

.005)

and

for bedtime

(57%

vs

39%,

P

=

.009).

The

only

other

sleep-related

item

on

the

10-item

child-functioning

scale

was ease

of

resettling

at

night.

This item

approached

statistical

significance favoring

the intervention

group

(65%

vs

53%,

P

=

.12).

There

were no

statistically significant

differences

between

groups

on

the other 7 items.

To

determine whether

parents

followed

our

in-structions,

we

compared

the

control and

intervention

groups

with

respect

to

parental

presence

at

bedtime.

Parental

presence

at

bedtime

was

significantly

less

common

in

the

intervention

group

compared

with

the

control group

(21%

vs

33%,

P

<

.05),

suggesting

that

at

least

some

parents

had

followed the

instruc-tions.

Among

intervention

parents,

those

who

were

not

present

when

their

child

fell

asleep

were

less

likely

to

report

frequent night waking

(9

%

vs

31

%,

P

=.002)

and

noted

fewer

night wakings

in

general

(1.

6

vs

6.0

awakenings

per

week,

P

=

.00

2).

However,

breast-feeding

was

not

reduced

in

those

infants

who

fell

asleep

without

parental

presence

(intervention

vs

control,

16%

vs.

19%,

P

=

.47).

To

determine whether the

Daily

Routine

Chart

was

effective,

we

compared

those who

completed

the

daily

routine

chart

(n

=

125)

and those who did

not

(n

=

26)

with

respect

to

the

occurrence

of

night

waking

or

frequent night waking.

No

significant

dif-ferences

emerged,

suggesting

that the

Daily

Routine

Chart

was

not

the

important

aspect

of

the

interven-tion.

DISCUSSION

This

study developed

and evaluated the

effective-ness

of

a

pediatrician-based

intervention

to

reduce

night waking

that

requires

parents

to

resettle their

child.

The results demonstrate that the

program

is

effective.

The

strength of the

intervention is

that it is

brief and

readily

accepted by

practicing

pediatricians

and

parents.

Future

studies

will

be needed

to

determine which

specific

aspects

of

the intervention

are

important

to

586

REDUCING NIGHT

WAKING

IN

INFANCY

at Viet Nam:AAP Sponsored on September 1, 2020

www.aappublications.org/news

TABLE 1. Infant and Parent Characteristics: Control and Intervention

Group

Characteristic Control

Group

Intervention

Group

PValue

(n

=

128)

(n=

164)

Infant

Meanage,m 9.4 9.2 .05

Gender, % male 55 54 .94

Ethnicity,

% white 95 98 .09

Mean,birth

weight,

g 3454 3472 .81

Siblings,

% present 52 58 .30

Parent

Maternalmeanage,y 30.6 29.2 .18

Paternalmeanage, y 32.6 32.5 .88

Maternaleducation,%

high

school

only

29 31 .33

Paternaleducation,%

high

school

only

41 36 .44

Family

Income,%>$30000 82 84 .76

Maritalstatus,% married 95 97 .15

TABLE 2.

Impact

of the Intervention

Control

Group

Intervention

Group

PValue

(n

=

128)

(n=

164)

Night

walking,

mean/wk

3.9 2.5 .02

Frequent

night walking

% 27 14 .01

reduce

night

waking.

However,

the

present

findings

suggest

that

reducing

parental

presence when

their

infant falls

asleep

is

effective

in

reducing night

wak-ing.

While

a

direct

cause-effect

relationship

is

possi-ble,

it is

also

possible

the

intervention

changed

an

intermediate

factor such

as

the

parents'

ability

to

separate

comfortably

from their

infant

at

bedtime

or

the

parents'

confidence

in

their

parenting

role. Such

attitudinal

changes

may also be

imnportant

compo-nents

in

reducing

infant

night waking.

The

apparent

lack

of effectiveness of the

sleep

chart

may be due

to

its

implementation

4

months

before the

outcome

was

measured. The role

of the

pediatrician

also

needs

to

be

systematically

evaluated. The context,

timing,

and

vehicle

(video

vs

written

vs

interpersonal)

in

which

information

is

provided

within

pediatric

primary

care

should also

be

investigated.

Concerned

professionals

have noted that many

nonindustrialized cultures

do

not

separate

infants

from their

parents

during

the

night.2

Infants

may

wake

frequently

and be

breast-fed

or

soothed.

In

our

culture,

clinical

experience

suggests

that

parents

value

uninterrupted sleep

at

night.

WVhile

separating parent

and

child

prior

to

the child's

completely

falling asleep

reduces

night

waking

among

infants,

it

also

reduces

parental sleeplessness.

This

may

increase

parental

energy and satisfaction

with

their

infant,

thereby

improving

the

parent-child relationship.

On the

pre-sumption

that

some

parents

might

not

be

comfortable

with

this

advice,

the

intervention

information

was

presented

as a

suggestion

rather than

an

imperative.

The

similarity

in

rates

of

breast-feeding

between the

two

groups indicates that the

intervention

did

not

have the undesirable

effect of

reducing

the

proportion

who

were

breast-feeding

at

9

months.

The

study

has

important

limitations that should be

considered when

interpreting

the

.findings.

First,

the

results

of

the

study

are

limited

to

young infants

in

a

middle-

to

upper-class population, thereby reducing

the

generalizability

of the

findings.

Future

investiga-tions

should

address the

effectiveness and

applicabil-ity

of

this intervention in

more

diverse

populations.

Second,

all

information

regarding

the

independent

and

dependent

variables

were

provided by parental

report,

without

objective

verification.

WVhile efforts

were

made

to

obscure the

purpose of the

study,

it is

possible

that

intervention

parents

provided

responses

that

they regarded

as

desirable but that

were

not

accurate.

Finally,

this

study

used

a

historical control

group and

was

not

a

randomized

trial.

However,

the

two

groups

came

from the

same

practice

and

were

similar with

respect

to

demographic

variables.

We

did

not

believe

a

randomized trial

was

possible

in

the

practice

because

of

a

potential

'halo'y effect of the

intervention.

We

hope

that

this

study

will

serve

to

stimulate the

development

and evaluation of other

interventions

by pediatricians

in

order

to

promote

favorable child

behavioral and

developmental

outcomes.

ACKNOWLEDGMENTS

Thisresearchwas

supported by

agrantfrom theMaternalChild Health Division of Health and Human Services

(MCJ 009094),

which

supported

DrAdair's

Fellowship

inBehavioral and

Devel-opmental

Pediatrics.

We thank Drs. Suzanna Alvarex, Arthur Lavin, Alan Nauss,

Pamela

Swearingen,

and Claire

Wilson,

of the

Department

of Pediatrics and Adolescent Medicine at the

Lahey

Clinic Medical Center

(Burlington,

MA).

This

study

was

possible only

becauseof their remarkable

cooperation

within the

setting

of a very

busy

pediatric

practice.

Wealso thank Ronald Barr, MD,

Betsy

Lozoff, MD, and Steve Parker, MD,for their

helpful

comments.

Finally,

wethank Catherine DeMilleat the

Lahey

Clinic Medical Center and

Kerry

Rafferty,

Margaret

Stanhope,

andJeanne

McCarthy

at Boston

City

Hospital.

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24. LozoffB,BrittenhamG.Infantcare;cacheorcaring.IPediatr. 1979;95: 478-483

ABSTRACT

Pizzaro

D, Posada

G,

Sandi

L,

Moran

JR.

Rice-based

oral

electrolyte

solutions

for the

management

of

infantile diarrhea.

New

England

Journal

of

Medicine.

1991;324:517-521.

The

investigators

conducted

a

randomized,

double-blind

study

to

evaluate the

safety

and

efficacy

of rice-based solutions

in

the

management

of mild

to

moderate

dehydration

in

infants with

acute

diarrhea.

They

studied

86

infant

boys,

3-18

months

of age,

in

Costa

Rica.

They

did

not

study girls

because

separate

collection

of

urine

and stool from infant

girls

is

difficult unless catheters

are

used. The

infants

were

randomly

assigned

to

one

of three

treatment

groups: group

A

received

a

rice

based

electrolyte

solution

containing

30

grams

of

rice-syrup

solids

and

50

mmol

of

sodium

per liter

(Ricelyte),

group

B

received, the

same

solution with the addition of

5

grams

of

casein

hydrolysate

per

liter,

and group

C

received

a

commercial oral

rehydration

solution

containing

75

mmol

of sodium and

25

grams of

glucose

per

liter

(Rehydralyte).

The

randomly assigned

solutions

were

administered

in

volumes

twice

as

great

as

the estimated

fluid deficit

over

4-6

hours. If

the

infant refused

to

drink

or

vomited

frequently,

the solution

was

administered

by

nasogastric

tube

at

15

ml

per

kilogram

of

body weight

per

hour.

The

investigators

found

that the

solutions

containing rice-syrup

solids

were

superior

to

a

glucose

based solution

in

decreasing

stool

output

and

that there

was no

advantage

in

adding

casein

hydrolysate

to

one

of the

rice

solutions.

However,

because

of the

potential hyponatremia,

the authors did

not

recommend the

rehy-dration solution

containing

50

mmol

of sodium for children with cholera.

Only

one

child

in

the

entire

group

(with

a

high

stool

output

and

persistent

hyponatremia)

required

intravenous

therapy.

Comment: From

an

historical

point

of

view,

it is

important

to

give

credit

to

the

millions

of

Asian

mothers

who

knew,

centuries

ago, that

rice

water

mixed with

a

little salt

was

useful

treatment

for diarrhea.

Submitted

by

Karen

Olness,

MD

588

REDUCING NIGHT WAKING

IN

INFANCY

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1992;89;585

Pediatrics

Robin Adair, Barry Zuckerman, Howard Bauchner, Barbara Philipp and Suzette Levenson

Reducing Night Waking in Infancy: A Primary Care Intervention

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Robin Adair, Barry Zuckerman, Howard Bauchner, Barbara Philipp and Suzette Levenson

Reducing Night Waking in Infancy: A Primary Care Intervention

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