Welcome to the ARACY webinar

Sleeping like a baby – not! Evidence and current controversies

Presented by Associate Professor Harriet Hiscock

Wednesday 6 August 2014, 12.00pm-1.00pm AEST Brought to you by the Early Years Chapter (EYC)

We will be commencing the webinar shortly as we wait for attendees to join us.

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Sleeping like a baby – not! ARACY webinar August 2014

Associate Prof Harriet Hiscock Centre for Community Child Health at The Royal Children’s Hospital, Murdoch Childrens Research Institute, Department of Paediatrics, University of Melbourne

Overview • ‘Usual’ baby sleep and crying patterns • Evidence-based strategies for: Babies < 6 months of age Babies > 6 months of age – Sleep Study • Controversies • Future research EK

4 month old boy • Crying/irritable “since birth” • Hyper alert and sensitive to his environment • Takes 1-2 hours to get to sleep with rocking, walking etc • Falls asleep at 11pm; wakes 1-3 hourly • Catnaps for 40 mins during the day • Told it was “colic” but has not grown out of it • Have tried multiple formulas, medications, chiropractor etc…. • Will “only” sleep if in bed with mum……

“Usual” sleep patterns • First weeks home – sleep  feed  sleep → feed etc

• From 3 weeks - more night sleep – “sleeping through” ie block of sleep lasting 8 hours: median age 3 months1

1 Henderson et al 2010

Settling into a pattern 24-hour sleep duration (Price et al Arch Dis Child 2013)

Centre for Community Child Health Normal sleep cycles Sleep cues

• The way we fall asleep at the start of the night is the way we expect to return to sleep when we wake overnight from REM sleep • So if the last thing a baby remembers is falling asleep on the breast/bottle, in ’s arms etc....then that is the way they want to return to sleep if they wake overnight. Infant sleep problems Infant sleep problems • night waking, difficulty settling to sleep or both • affect 30-45% of Australian infants1,2

Associated with adverse outcomes • double - triple the risk of postnatal depression1 • poorer maternal physical functioning1 • costly to treat (health service use $AUS 290/family from 8-12 months)3

1Bayer et al, J Paeds Child Health 2007, 2Martin Pediatrics 2007, 3Hiscock Arc Dis Childhood 2008

What causes sleep ‘problems’? • Only a ‘problem’ if think it is • Even then, may be normal behaviour • “Problems” may be due to: – learned settling behaviours eg rocking to sleep – medical causes eg cow’s milk allergy – sub-optimal -infant relationship – combination of these.... Suboptimal mother-child relationship

von Hofacker et al. Infant Mental Health J 1998; 19: 80-201. Management Needs to be: – tailored to the ‘cause’ – feasible for family – meeting family’s goals (not yours!) Should include: – normal sleep, sleep cycles and sleep cues – bedtime routine – range of options from which family can choose ...no one size fits all!

The tired baby • Tired signs – jerky movements – frowning – grizzling – crying

• Often misread as boredom, hunger • Rough guide: – aged 5-6 weeks tired after 1 ½ hours – infants aged 12 weeks tired after 2 hours

Recognising tiredness | Raising Children Network 6/ 06/ 11 10:11 AM

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Recognising tiredness Years

BABIES By Raising Children Network add to favourites email save PDF print

3-12 months

Behaviour Young children get overtired easily. When they do, they find it harder to get to sleep. Once you can spot those

Connecting & telltale signs of tiredness, you’ll be able to settle your child to sleep before grumpiness sets in. Communicating

Development

Health & Daily Care Children show they’re tired through changes in behaviour. For example, your child might be suddenly irritable, overactive or demanding. It’s important to look for your child’s ‘tired Nutrition signs’. This can help you reduce stimulation and start settling your child before overtiredness & Learning sets in. Safety

Sleep Newborns

The basics Newborn babies will probably get overtired if they’ve been awake for more than 1! hours. At 3- Sleep options 6 months, your baby will be overtired after 1! -2! hours awake. Sleep environment If your newborn is tired, you might see some of the following tired signs: Sleep issues pulling at ears Understanding sleep closing fists About sleep fluttering eyelids Sleep: 2-12 months jerky arm and leg movements Sleeping through the night yawning Recognising a worried look on your child’s face tiredness arching backwards Solving sleep problems difficulty focusing (your child might even go cross-eyed)

View videos sucking on fingers (this could be a good sign and mean that your baby is trying to find ways to settle to sleep).

Babies and toddlers

At 6-12 months, your baby will be overtired after 2-3 hours awake. At 12-18 months, your baby will be overtired if baby misses out on the morning or afternoon sleep.

TiredIf your basignsby or to –ddl olderer is tire d,babies you migh t see some of the following tired signs:

clumsiness

clinginess

grizzling

crying

demands for constant attention

boredom with toys

fussiness with food.

Grizzling and crying can mean your child is absolutely exhausted, but it’s often hard to tell the difference between tired grizzling and hungry grizzling.

Reducing stimulation

If your child is showing signs of tiredness, you can reduce stimulation by:

taking your child to the place where your child usually sleeps

putting toys away

talking quietly and soothingly

closing curtains and blinds

turning overhead lights off – use lamps if you need to

playing music quietly – this will help cut down on background noise. http:/ / raisingchildren.net.au/ articles/ is_m y_child_tired.html/ context/ 730 Page 1 of 3 Option 1: Modified controlled comforting • Aims to teach baby to self-settle • Put baby into cot drowsy but AWAKE • Parent settles baby at 1-2 min intervals if baby crying • Settle by stroking, patting, gentle rocking in cot; one strategy at a time! VERSION: listen to infant cry rather than timing…. Option 2: Camping out (adult fading) • More gradual • Parents place camp bed/chair next to bed and pat baby until asleep • Once baby is used to this, pat the mattress until baby asleep • Gradually remove their bed/chair from baby’s room over 2 to 3 weeks • Go at baby’s pace… Camping out • Parents must return to the bed/chair when their baby wakes overnight • Parents need to ignore any “games” and keep it boring!

Strategies to manage the unsettled baby: over 6 months of age Evidence-based strategies

Infant Sleep Study - randomised controlled trial

Maternal and child health centres in 6 local government areas

328 8-mnth healthy infants with parent reported sleep problems

Intervention • nurse delivered • 1-3 appointments to discuss normal sleep and settling strategies • sleep diary • written management plan and education materials

Control – usual care Strategies offered Controlled comforting (graduated extinction) – baby into cot drowsy but awake – parent returns if baby crying at increasing time intervals eg 2,4,6,8 minutes – settles either briefly (ie < 1 minute) OR until baby quiet but not asleep OR Camping out Outcomes

• Intervention improved: – sleep problems at infant age 10 and 12 months – maternal depression symptoms at 10 and 12 months – maternal sleep quality and quantity at 12 months

• Intervention was cost effective – costs to health services per family: $241 (intervention) vs $290 (control) – fewer residential stays at early centres

Hiscock at el Arch Dis Child 2007

EK – 4 month old baby Management – discuss normal sleep, sleep cycles and sleep cues – discuss tired signs – offer modified controlled comforting and camping out – let mother choose! – sleep diary – REVIEW progress sooner rather than later

Current controversies Does controlled comforting cause harm?

Follow up of Infant Sleep Study children at age 1, 2 and 6 years; half had received controlled comforting/camping out at 8 months and half had not

• At age 1 85% of reported a positive intervention effect on the mother-child relationship

• At age 2 intervention compared with control families had fewer persistent sleep problems (11 vs 22%) less maternal depression (15 vs 26%) no difference in child behaviour or parenting

• At age 6 years no difference in child sleep, behaviour, parent-child relationship or salivary cortisol (marker of child stress)

Hiscock 2007; Hiscock 2008; Price 2010; all Pediatrics Cortisol and extinction method Middlemiss et al. Earl Hum Dev (2012) • 25 infants enrolled in a 5-day inpatient sleep training program using unmodified extinction (crying-it-out). • Salivary cortisol sampled (infants and mothers) on night 1 and 3, at “initiation of the night sleep routine” and “20 min after infants’ onset of sleep”

Conclusions: “mothers’ and infants’ cortisol responses were positively associated at initiation of nighttime sleep following a day of shared activities…. On the third day of the program, however, results showed that infants’ physiological and behavioural responses were dissociated. They no longer expressed behavioural distress during the sleep transition but their cortisol levels were elevated. Without the infants’ distress cue, mothers’ cortisol levels decreased”

Cortisol Results: Sleep • “On the first day of the sleep training program, all infants engaged in 2 or more bouts (5-10min) of crying. In contrast, by the third day of the program, all infants settled to sleep independently without a bout of distress signaled through crying.” (p.230)

Cortisol

Night 1 Night 3 difference

Infants .453 ±.769 .512 ±.900 + .06 Negligible difference .580 ±.904 .412 ±.675 - .21 Small decline Mothers Middlesmiss response • “the depth of our knowledge does not enable us to make judgements about good or bad levels of cortisol”

• “given the small sample size, ...firm conclusions for policy and practice cannot be reached from the data presented” Future research • Rigorous trials of alternative approaches to settling eg parental presence, more cue based responses • Subgroup analyses and focus groups to identify which infants benefit from which approach • Document infant wellbeing in short, medium and long term - ? with cortisol but only if we can interpret changes... Conclusion

• Understand natural history of sleep, sleep cycles and sleep cues • Exclude medical causes first (uncommon) including cow’s milk allergy • Offer parents a choice tailored to their goals and feasibility • Use a sleep/cry diary to monitor progress • If things do not improve, consider medical cause, PND, family dynamics....offer a different strategy Web based resources • www.raisingchildren.net.au (for parents and professionals, 0-18 years)

• PURPLE CRYING website http://www.purplecrying.info/

• Online infant sleep training http://www.learninghub.org.au/course/category.php?id=10

Acknowledgements • Families and nurses who took part

• Co-investigators: Melissa Wake, Obi Ukumoune, Jordana Bayer, Fiona Mensah

• Funders: NHMRC, Victorian Dept Education and Early Childhood Development, Sleep Health Foundation, Gandell Foundation

Thank you for attending

PowerPoint and audio recording

To be available in Resources > Publications Library > Presentations section on the ARACY website

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