Infant sleep as a topic in healthcare guidance of parents, prenatally and the first 6 months after birth: a scoping review

Abstract

Background

This scoping review focuses on infant sleep-related factors and themes that are relevant when health practitioners provide preventive health services to expectant and new parents.

Methods

A systematic literature search in CINAHL, PubMed, and PsycINFO, published in 2010 or later, identified 1661 records. The search was further narrowed to focus on sleep in healthy term-born infants until the second half of the first year of life. A blinded review by both authors covered 136 papers, of which 43 papers were reviewed in the full text. Finally, 38 articles were included in the data extraction.

Results

The analysis process showed that the selected studies formed three main information categories: 11 studies thematised safe infant sleep issues, 10 studies described design and findings from sleep-related intervention studies, and 17 studies focused on different parent-child interactive aspects that may influence the quality and duration of infant sleep in the first six months of life.

The main finding is that knowledge about early infant sleep is very complex, and includes both child, parent, and environmental factors. Several studies have shown that the concepts and factors related to safe infant sleep also influence the development of healthy infant sleep patterns. Thus, these aspects are interwoven with each other and should be addressed together in communication with parents.

Conclusions

Health practitioners with different professional backgrounds need to search for an agreement on when and how different aspects of sleep-related knowledge should be communicated to new and expectant parents to enable the design of national follow-up programs. Parents want coherent and personalized services regarding infant sleep issues that may allow them to choose sleeping arrangements, routines, and behaviors that fit in with their sociocultural attitudes and traditions. Many different sources and formats may be used to empower parents regarding infant sleep issues. Studies have described the use of group or individual meetings, videos, and written materials. The key issue is the importance of consistent and seamless knowledge-based services.

Background

Establishing nighttime-sleep (NTS) in early infancy is challenging for many parents. Both professionals and parents have summarized these difficulties in recent Norwegian publications [1,2,3] and research has documented that many parents struggle to follow advices on safe infant sleep, despite regular campaigns to promote such information [4]. The importance of sufficient sleep is well known, and updated recommendations on sleep duration for groups of children aged five years or less were published by the World Health Organization (WHO) in 2019 [5]. Short sleep duration or interrupted sleep in infancy is associated with increased sleeping difficulties later in childhood [6], as well as risks of a range of health problems [7, 8]. Infant sleep is a complex phenomenon associated with factors as parental sleep and mental health [9], maternal sensitivity [10] and parental practices [11].

Most healthcare professionals know that the first six months of infancy are characterized by maturation and sleep consolidation [12, 13]. The term “sleep problems” is rarely used until the infant enters the second half of the first year [1]. Research has identified this early consolidation phase as important for determining whether sleep-related problems occur later in infancy or toddlerhood [14, 15].

Parent facilitation of infant sleep is thought to be influenced by the baby’s and parents’ and caretakers’ personalities, family context, economy, general environment, and cultural traditions [16]. Research emphasizes the importance of a good alliance with healthcare professionals when establishing safe and development-promoting sleep [17]. Although there is a large volume of research related to infant sleep safety, duration, and sleep hygiene, there is a lack of research exploring how health professionals can strengthen parents’ experience of self-efficacy, and how this relates to the way sleep-related advice is communicated. We find few publications from North European countries other than the United Kingdom (UK). Northern Europe is characterized by rapid demographic changes, as in most of the world [18]. Because of education or work, young people frequently move away from their families. This may weaken their social networks in the phase of life in which they become parents. Living conditions, sometimes in small apartments, may provide limited opportunities for safe infant sleep. Northern Europe is a region with a colder climate and greater seasonal variations in light and temperature than Mediterranean and tropical zones. Seasonal light shifts and polar nights are known to affect sleep among adults [19]; however, little is known about the degree to which these factors affect infant sleep development and habits. Several Northern European countries are recognized as having some of the best health welfare systems in the world [20], but we have been unable to find information that links health system quality to follow-up systems for infants and new families.

Existing safe infant sleep advice seems to be based on at least two strong paradigms [21, 22]: the risk-elimination approach advocated by the American Academy of Pediatrics (AAP) and a risk-reducing, cultural, and neurobiological approach that addresses what is thought to be natural for human beings [23, 24]. Advice and counseling must be relevant for parents and conveyed in a sensitive and understandable way, taking into consideration cultural differences [25]. There seems to be a lack of studies addressing which topics of sleep advice should be addressed and when. When screening publications over the last 20 years, we detected interventions initiated during pregnancy [26], maternity wards [27], and postnatal care [28, 29]. Research shows some inconsistencies in advice and the factors that influence parents` adherence to safe sleep guidelines, and many parents do not use safe sleep practices at home [30, 31]. Preventive communication about infant sleep includes many topics, and short interventions seem to have the best effect on parental adjustments to infants’ sleep [32, 33].

It is important to understand what healthcare professionals who meet expecting and new parents through pregnancy, childbirth, and postnatal care follow-ups should consider when providing support and information. Altogether, these services aim to promote both safe and developmentally preferable sleep in infants and healthy role transitions for mothers, partners, and families [34, 35]. These topics are addressed in this review in an attempt to provide an overview of different aspects that may be included in coherent, seamless services for new families. The topics addressed are also consistent with health-related goals launched by the Department of Health and Care, UK [36]. The research question guiding the review is as follows: “Which factors are described as important in health personnel’s guidance of expectant and new parents when the goal is safe and well-consolidated infant sleep?

Method and material

The theoretical framework for scoping reviews has been known for fifteen years [37]. This methodology is recommended for investigation of complex phenomena and allows different sources of information to be selected, depending on their relevance to the questions asked. Scoping review is characterized by a processual work where all parts must be systematic, transparent, and credible. The methodology is reframed in recent years by a research team affiliated to the Joanna Briggs Institute (JBI) [38,39,40]. The original methodological steps focused on defining a research question, systematic searches followed by reasoned selection of studies, summarization and report of the results [37]. The updated framework emphasize that an analysis of the findings is made and that this is an essential part of further presentation of results. In line with the JBI recommendations a research protocol has been formed and published on Open Science Framework (OSF) [41]. This study deals with interactions between different groups of individuals, as displayed in the search strategy (Table 1). This study focuses on sleep concepts and factors described as important for health professionals to address in dialogues about infant sleep, both prenatally and after birth. These contexts, where parent-infant dyads meet with health practitioners, might vary somewhat depending on the health service organization in different countries. This review focuses on regular health-promoting follow-up services for new or expecting parents without known illnesses or risks. Infant sleep information and guidance may be taken care of by different groups of professionals in pregnancy (by midwives or general practitioners [GP] physicians), maternity wards (by midwives, nursery nurses, or pediatricians), or during infancy (by midwives, health nurses, GP physicians, or other services). In this paper, they are all named health practitioners, and guidance may be given as instructions, information, discussions, etc.. This review is not designed to recommend any form of guidance; thus, we address this as a communicative interaction.

Table 1 Data search strategy

Infant sleep outcomes may be bidirectionally influenced by parental mental health and nutritional arrangements during infancy [42, 43]. The authors recognize the importance of these factors, but choose to focus solely on infant sleep outcomes. Table 2 summarizes the criteria that guided systematic searches of the PubMed, CINAHL, and PsycINFO, databases. Table 1 shows the search strategy used.

Table 2 Inclusion and exclusion criteria for data selection

This review focuses on infant sleep and parental advice in countries characterized by a subarctic or continental climate, corresponding to European countries north of the Alps. However, we considered research from all the geographic regions. Additional searches have been conducted using terms as “seasonal, season, polar nights, cold climate” in combination with infant sleep. This iterative search process is in line with updated methodological advices [39]. The included databases enabled us to detect publications in the most relevant fields of research, such as nursing, midwifery, child health, medicine, and psychology. Owing to the large number of papers addressing infant sleep in this multidisciplinary field, no publications older than 2010 were considered. This limitation also seemed appropriate because previous research is largely included in later reviews. An overview of the data-selection process is presented in Fig. 1.

Fig. 1

PRISMA ScR flow-chart

After importing the items to Rayyan [44], two reviewers performed blinded examinations and assessments of each source and their relevance for inclusion in repeated steps. Disagreements were resolved by discussions and repeated review of the title, abstract, and, in some cases, screening of the full-text versions. The scope of this process is illustrated in Fig. 1.

The thematic focus of the review is identified as complex, involving many environmental, parental, and child factors, in addition to relations between different participants [16, 22]. While working on the study protocol, we decided to use a framework adapted from a well-known transactional model of infant sleep to guide data extraction from each study and summarize topics and factors [16]. This model seems helpful and enables us to discuss how different aspects involved in the facilitation of infant sleep relate to each other.

Results

Tables 3, 4, and 5 present 38 selected articles. Information about the first author, country, year of publication, aims and participants, main results, key factors, and possible implications are listed as requested [45]. More than half of the selected studies originated from the USA (21 studies), while seven were published in Oceania, eight in Europe, one in Asia, and the last was a collaborative product of European and Asian authors.

Table 3 Studies regarding infant sleep safety (Alphabetic ordered after first author)

Table 4 Development and evaluation of sleep related interventions. (Presented in publication year order)

Table 5 Studies exploring aspects associated with infant sleep quality (Alphabetic ordered after first author)

The included studies shaped three main categories of information that answered our research question. Table 3 presents 11 studies on infant sleep safety (7 original studies and 4 reviews). Table 4 presents nine studies describing complex or specific infant sleep interventions, relevant until infants age of 6 months (five original studies and four reviews) and Table 5 presents 17 studies exploring factors that may have an impact on infant sleep quality and duration until 6 months of age (16 original studies and 1 review). Quality assessment of the included studies is not obligatory when conducting a scoping review. However, the detection of recently published high-quality papers has become a priority in the selection process because several important sleep-related factors have been investigated in many original papers and reviews over the last 10 years. The factors suggested for incorporation into health practitioners’ communicative interactions with new parents are listed in Fig. 2. Unfortunately, additional searches focusing on sleep and climatic factors, such as polar nights and seasonal lightning, did not identify studies that qualified for inclusion in this review.

Fig. 2

Factors to be considered in health practitioners’ communicative interactions with new or expectant parents

Discussion

This study investigated which factors are described as important in health practitioners’ communicative interactions with new and expectant parents on infants’ sleep safety and development. We recognize that topics related to parents’ health and their decisions regarding infant feeding are interwoven in the planning and nurturing of infant sleep. However, these factors are not discussed in this review. The following discussion is based on the three categories described in Tables 3, 4 and 5 and refers to many of the factors summarized in Fig. 2.

Studies regarding infant sleep safety

Table 3 includes 11 studies that investigated the effects of interventions promoting safe infant sleep in different educational programs. Seven studies described interventions based on the AAP guidelines which highlight the importance of back to sleep for infants, use of pacifiers in the first year, avoidance of soft sleeping surfaces, and items in infant beds that can increase the risk of SUID and warnings against parent-child bedsharing [24, 50]. Both short interventions, such as educational videos, and longer programs and campaigns have been described [32, 49, 51]. Four studies have discussed earlier research findings on similar topics.

Parents’ capacity to receive information in the perinatal period is described as limited [47, 48]; thus, how information about and modeling safe sleep issues are personalized and given is important [52, 76]. Health practitioners’ teaching strategies must be tailored to fit each individual family for success [47]. Several studies have emphasized the importance of updated knowledge and consistent practices among health practitioners [30, 49]. One important finding is that health practitioners in maternity wards should be educated in safe sleep practices and perform according to what they advise parents to do [30, 49]. By providing safe sleep practices in a hospital setting, health practitioners can influence parental behavior through modelling with their own practice [30, 31, 47].

Although highlighted safe sleep recommendations seem to be widely known and recommended, research shows that parents tend to form their own practice in their home environments [22, 28, 29, 47]. This applies particularly to the sharing of the same bed surface. Parents are influenced by family, friends, and society [16], as well as advertising and the Internet [77], and they frequently practice bedsharing despite AAP-recommendations not to do so [24]. In Europe, recommendations regarding parent-infant bedsharing (P-CBS) are articulated somewhat differently compared to those in the USA, depending on national policies [77,78,79]. Bedsharing is neither recommended nor discouraged in the UK. Swedish recommendations state that infants younger than three months should sleep in a cot, while Norwegian recommendations focus on how parent-child bedsharing can be performed safely [77,78,79]. Recent research has reported that bedsharing is not associated with an increased occurrence of SUID when other risk factors are considered [80]. Recent Scandinavian studies have reported increasing rates of bedsharing [4, 81]. A risk-reducing approach may thus be more acceptable in many European countries, as health practitioners recognize that co-sleeping occurs, and their advice can focus on how to facilitate intentional bed-sharing securely. This seems important, as reactive or spontaneous unplanned bed sharing is associated with an increased risk of injuries or SUID [21]. It seems important to share knowledge with parents in a non-judgmental way regarding how bedsharing may affect infants’ physiology. Cot versus co-sleeping arrangements influence sleep outcomes, such as sleep architecture, arousal, and overnight temperature control [46]. Longer sleep durations have been reported among solitary-sleeping infants than among co-sleepers [80]. The last finding may be biased by the fact that co-sleeping mothers seem to recognize night waking among their infants more easily than non-co-sleeping mothers [23].

Many families live in space-restricted apartments. This may limit the use of a separate baby bed. A cot-distribution program that included early antenatal communication reported positive outcomes [51]. In a study investigating the use of cardboard boxes distributed through a pediatric primary care clinic in the United States, more than half of new parents reported that they would use the cardboard box for their infant to sleep in if provided [82]. Considering the family environment (Fig. 2), the distribution of cardboard boxes can also encourage safe sleeping in families with low economy [82]. Finland has long traditions in supplying new families with a card board box to encourage safe sleep, and is known to have low SUID rates [83].

The purpose of parental guidance is to empower parents and address their own expectations, experiences, and opinions as well as family culture while sharing sleep-related knowledge with them (Fig. 2) [16, 22]. One communication topic may be that the use of a pacifier while sleeping not only affects the infant’s regulative behavior, but also reduces the risk of SUID, possibly because repeated sucking promotes more light sleep [31, 48, 49, 84]. When parents are offered understandable and knowledge-based advice, it may be easier for health practitioners to establish trustworthy relationships with new families. When respectful alliances are formed, parents may be more likely to find advice and recommendations relevant to them [35]. Our review shows that guidance and recommendations can be promoted through different approaches, which should be consistent and knowledge-based.

Development and evaluation of interventions addressing infant sleep consolidation

Six studies, published in the last 5 years, describe infant sleep-related interventions with high relevance for the early postnatal period [26,27,28, 56, 58, 59]. In addition, four reviews summarize earlier studies and discuss the degree to which sleep-related interventions may increase sleep outcomes in the postnatal period of life [29, 53,54,55]. One intervention was started antenatally, two were implemented in maternity wards, and three were designed to support families at postnatal follow-up meetings.

Different theoretical frameworks appear to inform the design of the interventions and studies included. Several interventions aim to teach parents about infant sleep and how they can promote early consolidation of sleep habits in their infants [27, 56, 58, 59]. Ball et al. (2020) introduced an alternative approach focusing on parents’ need for knowledge about normal sleep development, homeostatic sleep pressure, healthy activities when awake, the importance of cued-based care, and that advice should be adapted to each family and their cultural preferences [28].

This review will not explore the gaps between different approaches, but some gaps seem important and may reflect the different conclusions reported in the reviews included [29, 53, 55]. A review from 2013 concluded that behavioral sleep interventions during the first six months of life do not have significant effects on infant sleep [53], while later reviews reported several positive effects [29, 54, 55]. Some studies found that early interventions may increase infants’ night-time sleep [26, 54], reduce the frequency of nightwakings [71], increase the use of recommended early bedtimes for infants [56], prevent prolonged bedtime routines, eat as the last activity before sleep [27, 56], and help infants to sleep more regularly in their own cot [27]. No intervention reported effects related to the duration or frequency of infant crying. This concurs with a previous suggestion that infant crying in the first months of life depends on the maturation and biology of each individual child [57].

Studies investigating aspects associated with infant sleep quality

The final group of studies consisted of 16 original studies and one review addressing different sleep-related factors (Table 5). All studies focused on aspects of the parent-infant interactive context related to sleep quality (consolidation) or infant sleep duration (Fig. 2). Parent behavior related to bedtime routines and/or night-time behavior has been addressed in six studies [14, 60, 69, 70, 73, 74]; two studies focused on the benefits of regular babymassage [61, 65] and two on the benefits of regular swaddling [68, 71]. One US study reported results related to parent-infant sleep and room sharing [72], one Turkish study reported significant improvements in infant sleep after teaching parents different soothing techniques [75], and two studies reported somewhat contrasting findings related to associations between infants’ daytime screen-viewing and infant sleep [64, 66]. One study report findings related to the impact of parents’ emotional availability in interactions with their child prior to sleep [69], while another report that parents use of “cry it out” strategies is not associated with negative outcomes at children’s age of 18 months, even when this strategy has been used across the first month of life [62]. One study addressed the importance of varying the direction of the infant’s head when initiating sleep because the skull of a newborn baby is soft, thus increasing the risk of cranial asymmetry [67]. Parents need appropriate information about this, and an education program designed for nurses has been reported with promising results [67]. Advice on the use of the correct type of pillow may conflict with safe sleep recommendations. Lastly, an Italian study confirmed previous findings of much more variation in infants’ sleep consolidation in the first versus second half of the first year [63].

The studies mentioned above were selected because they tap different aspects highlighted in the transactional model of infant sleep [8, 16]. Thus, it is important to consider when health practitioners design communicative interaction programs for new parents. Many studies confirm the importance of consistent bedtime routines as early as possible during the postnatal period [14, 60, 65, 69, 70, 73]. The importance of consistent, multicomponent routines flexibly adapted to each child may not be obvious to new parents. Parents may need information about the advantage of putting a newborn to sleep drowsy but awake, or to be introduced to the use of babymassage with lotion as a part of a routine, along with other elements fitting in with their traditions and values [47, 52]. Many parents need basic information about massage rather than touch and tender patting of the skin [15, 65, 69, 70]. The need for more knowledge may also apply to swaddling [68, 71].

The factors mentioned above may influence both safe sleep arrangements for infants and how parents can support the optimal development of regulative behavior and sleep consolidation in their child [31, 47, 71]. Thus, interventions for new or expectant parents and infants should combine communication about safe infant sleep and advice about how they can influence sleep consolidation in their child. This new paradigm was introduced by Mileva-Seitz and colleagues [21]. The holistic and cue-based intervention SBY, designed in the UK in close collaboration with many stakeholders, seems to be a good starting point [28]. Nevertheless, we could not identify any focus on infant safe sleep issues in the SBY program description. A recurrent theme across included studies is the importance of giving parents knowledge about newborn infants’ sleep behaviors and states, and that these patterns differ significantly from sleep in older infants and adults [26, 55, 58, 75]. A similar focus is prominent in the framework of newborn behavioral observation (NBO) [2, 35], where health practitioners are educated on how to help parents understand and adapt to their children’s sleep and other behaviors. NBO focuses on how to understand infant behaviors as meaningful expressions, helping parents adapt to them, and finding helpful parenting solutions. The NBO approach appears to be a powerful tool to consider when designing new sleep-related interventions. Even in the first months of life, when rhythms involving eating, sleeping, and social interactions are characterized by a lack of regularity, parents seem empowered when they discover their infants’ incipient competences [85].

Another recurrent theme is the importance of individualized and personalized guidance by parents on infant sleep issues, avoiding standard information packages [47, 52]. This is in line with a Scottish qualitative study of how new mothers want to be met and supported by health practitioners [86]. Mothers want to work in partnerships with professionals, obtain knowledge-based advice free of stigma, help establish realistic expectations, and encourage them to make their own choices based on their family’s needs [86]. This is almost a rewriting of the values promoted by NBO courses in Norway [35]. The famous words of the Danish philosopher Soren Kierkegaard, referred to as “the art of helping”, may be the best way to sum up this important theme: “If one is truly to succeed in leading a person to a specific place, one must first and foremost take care to find him where he is and begin there. This is the secret in the entire art of helping” [87].

One important reason why infant sleep becomes a challenge for new parents is short naps, night waking, and frequent infant crying behavior [88]. Several of the included studies dealt with crying behavior. High frequencies of infant crying have been reported in studies in many different countries and cultures, even though the amount of crying has been reported to be significantly different between nations [89]. Crying behavior is closely related to conditions in an individual infant, and systematic reviews have failed to detect interventions that significantly reduce crying behavior [57]. While some describe strategies such as delayed response or letting the baby “cry it out” as possibly harmful [28] one study reports no long-term negative effects of “cry it out” in the first six months of life on childrens’ attachment quality [62]. Philbrook and Teti reported that parents’ emotional availability may be more important than how they respond when settling an infant to sleep [73]. Another study reported that appropriate nighttime interventions in the first three months of life may support infant sleep consolidation. Non-distress-initiated interventions seem to disturb solitary sleepers differently compared to co-sleeping infants [74]. Different findings do not shape a clear picture, but several studies show that swaddling and soothing behaviors may reduce infant crying and fussiness [71, 75]. More research is needed to investigate whether or how different aspects of parental behavior influence infant sleep across the four quarters of the first year of life. A recent Finnish study documented that natural and artificial light have an impact on sleep architecture in 1 month old infants [90]. Climatic variations may also have an impact on infant sleep development; however, more research is needed to clarify the mechanisms involved.

Strengths and limitations of this review

The main strength of this study is the thorough follow-up of methodological advice on scoping reviews given over the last 20 years [37,38,39,40, 45]. The scope of the study was limited to advice on healthy infant sleep in the first 6 months of life. However, the selection of studies uncovered a complex and manifold package of knowledge. The authors have strived to select studies that are of high quality, recently published, and tap different important aspects involved in the facilitation of early infant sleep. Thus, previously important contributions to this field of knowledge may not be mentioned in this review. Studies focusing on how somatic health problems such as colds, itchy skin, and eating challenges may interrupt infant sleep were excluded.

Conclusions

This scoping review documents a wide range of factors and themes that may be relevant to early preventive communication with expectant and new parents. Factors related to safe infant sleep and healthy sleep development are interwoven. Health practitioners in regions with a common health policy should search for an agreement on how to combine these factors in communicative interactions with parents. Parents want coherent and personalized services regarding infant sleep issues, and health practitioners involved in follow-up services need to cooperate in the design of appropriate programs. Different sources of information can be used by different participants or technological platforms [91]. It seems important that professionals and stakeholders within each country come together to develop a common approach about when, what, and how to communicate important sleep-related knowledge to new families.