Isr J Psychiatry - Vol. 56 - No 2 (2019) MIRIAM FINK LAVI ET AL. The Effect of Preventive Guidance on Infants’ Sleep and Parents' Well-being Miriam Fink Lavi, MD,1,3 David Mankuta, MD,2,3 Julia Tamir Doljansky, MA,4 and Yoav Kohn, MD, MHA1,3 1 Department of Children and Adolescents, Jerusalem Mental Health Center, Eitanim Psychiatric Hospital, Jerusalem, Israel 2 Department of Obstetrics and Gynecology, Hadassah University Medical Center, Ein Kerem, Jerusalem, Israel 3 Hebrew University – Hadassah School of Medicine, Jerusalem, Israel 4 Psychologist in private practice for sleep disorders INTRODUCTION ABSTRACT About 30% of children under five years old suffer from Background: Sleep problems in infants negatively behavioral sleep problems: a need for prolonged presence affect quality of life and mental health of both babies of parents while falling asleep, waking up crying during and parents. Appropriate guidance for parents can the night, difficulty to wean from nocturnal feeding and assist in prevention. We assessed whether a preventive a tendency to move into the parents’ bed (1-3). While behavioral plan, emphasizing dissociation of feeding this situation affects the parents’ sleep and their ability to from sleep, can encourage independent sleep induction function under sleep deprivation, the children themselves in newborns, enable uninterrupted sleep and reduce are the ones who suffer the most. Deep and continuous maternal depression. sleep is essential for normal physiology and develop- Methods: Sixty-one mothers were recruited up to one ment (3-8). Emotional ramifications of intermittent sleep month postpartum. Thirty-two were selected randomly to include continuous frustration and suffering. Waking receive preventive sleep guidance. Twenty-nine served as up at night is frequently accompanied by crying, as the controls. Mothers kept daily records of their infants’ sleep child has awakened but is unable to fall asleep without up to 3 months postpartum. At endpoint participants assistance (1, 2). Sleep disorders in infants can disturb filled out the Edinburgh Postnatal Depression Scale. the sleep of their parents and by this it can negatively affect their health and quality of life. Research clearly Results: There were less night awakenings among the demonstrates that the lack of sleep has a negative effect intervention group (1.25 vs. 3.58; p<0.05). These mothers on functioning, homeostasis, memory, decision-making reported significantly less tiredness and lower stress and psycho-motoric skills in general and specifically levels and had a trend towards less symptoms of among postnatal women (5, 6, 9). There is also a direct depression. link between lack of sleep among both infants and par- Conclusions: We suggest that preventive sleep behavioral ents and the development of obesity, cardio-vascular guidance can be effective in sleep consolidation of infants illnesses, metabolism disorders and life expectancy (8). and reduction of fatigue and stress among mothers. Sleep deficiency was found to negatively affect the quality Our results call for more studies on early intervention of life and lead to moodiness, difficulties in adjusting programs as a means to reduce the impact of continuous to parenthood, strains on the couple’s relationship and sleep deprivation. parental fatigue and depression (3, 4, 10, 11). Infants’ sleep problems contribute to postnatal depression among mothers, with a prevalence of 13% (12-14). In a large- Funding Source: No funding was secured for this study. scale study (4), researchers found a high correlation between Financial Disclosure: Absence of financial disclosure elevated levels (>13) of postnatal depression as measured Conflict of Interest: No conflict of interest was present by the Edinburgh Postnatal Depression Scale (EPDS) (15), Clinical Trial Registration: IRB number: 0080-14-HMO and lower sleep quality as measured by Pittsburgh Sleep Address for Correspondence: Dr. Miriam Fink Lavi, Eitanim Hospital, DN Tzfon Yehuda, Israel 90972 [email protected] 11 THE EFFECT OF PREVENTIVE GUIDANCE ON INFANTs’ SLEEP AND PARENTs’ Well-beinG Quality Index (PSQI). This study established a link between at Hadassah University Medical Center, Ein Kerem, infants’ sleep patterns and the emergence of new depression Jerusalem. symptoms among mothers. As a result, researchers called to provide preventive support to reduce the harm caused INCLUSION CRITERIA by disrupted sleep in the postnatal period. Women >18 years old, following vaginal birth or Parental care requires identifying the physical and Caesarean section, who gave written informed consent emotional needs of the infant including: sleeping, eating, to participate in the study. affection, etc. However, parents tend to attribute fussiness and restlessness to hunger and automatically feed the EXCLUSION CRITERIA infant while overlooking the possibility of tiredness or 1. A neurological, developmental or physical disorder other needs. This response cycle may create an irregu- in the newborn. lar eating-sleeping routine, which includes fragmented 2. A premature baby, <35 weeks, according to the last sleep pattern and recurrent feedings. When a state of period date of the mother. sleep is achieved by the parents feeding the baby, they 3. Diagnosis of a psychiatric illness or a personality dis- usually return the sleeping child to the crib, thus creat- order in the mother. ing a change in the infant’s surrounding. This change in 4. Mothers under the age of 18. sleep surrounding may explain the fragmented sleep, accompanied by distress and crying when infants face the The research protocol was approved by the Hadassah absence of their parents upon arousing (16, 17). With time, University Medical Center Review Board. infants develop a strong dependency on the parent to get Recruiting procedure included providing study infor- assistance to sleep, while the parent increasingly relies mation leaflet and signing an informed consent form. on these practices. Creating a routine, which includes placing the infant in his/her bed and encouraging him/ PROCEDURE her to fall asleep independently, is recommended. During A serial enrollment procedure was executed by a physician the baby’s first weeks, there should be a clear separation (MFL). There were no refusals (0/61). Upon enrollment the between eating and sleeping (17, 18). An intervention participants were asked to fill out a personal detail form study assessed the value of behavioral methods in encour- and a medical questionnaire including questions about aging children to fall asleep independently (3, 19). The current and past psychiatric diagnoses and treatment. They project also assessed the effect of these methods on the were provided with sleep diaries, which match the gold behavior of toddlers and their emotional self-esteem. standard of polysomnography (PSG) (19). All participants After two weeks of implementing the independent bed- were asked to fill in sleep diaries during the first 12 weeks time method participants exhibited an improvement after birth. After enrollment, mothers were randomly in all sleep measures as well as in many behavioral and divided into two groups. The groups were allocated by psychological indicators. The American Academy of Sleep using the excel randomization tool. Participants’ personal Medicine also published similar results (20). details were decoded and kept apart from the physician The most effective approach to cope with behavioral who scored the clinical questionnaires. The interven- sleeping habits is to prevent them. This study is unique tion group included 32 women and the control group since it does not focus on treating existing sleeping prob- included 29 women who were treated as usual. Sample lems. Instead, it examines the contribution of a novel size was determined in order to allow significant results method of training to prevent association of feeding and using T test analysis. The intervention group participants sleeping. Our aim was to assess this method’s value in received sleep guidance based on the study rationale (see reducing sleep disorders among infants and to evaluate below) between 0-6 weeks after delivery. Both interven- its ability to reduce maternal depression and stress. tion and control groups were scheduled for a follow up visit 12 weeks after birth. During the first meeting with the intervention group, mothers received preventive sleep PATIENTS AND METHODS guiding. All mothers were given the option of a daily PARTICipaNTS consultation with the research team through email, which Healthy women during the first month following nor- was designated solely for this purpose. After 12 weeks, mal delivery. The enrollment was in the maternity ward mothers filled out the Edinburgh Postnatal Depression 12 MIRIAM FINK LAVI ET AL. Scale (EPDS) to identify postnatal depression symptoms. group has a power of 80% to detect a difference of 3.4 Participants were also contacted by phone to establish the points in the EPDS scale score with a significance level results of the sleeping diaries and sleeping habits. All the of 0.05. Previous studies found an average of 6.4 with an women who reported depression symptoms were referred SD of 4.6 points of this score in post-partum women. to psychiatric evaluation and treatment. None of them had No data were available to calculate sample size needed suicidal ideations or plans. to show difference in sleep patterns after training. All the mothers in the intervention group were included in the INTERVENTION statistical analysis. They were asked if they implemented The intervention we implemented was based on behav- the method; 5/32 reported that they decided not to use ioral sleep training which relies on encouraging the the intervention tools we suggested, and that their babies babies to fall asleep without or with minimum parental did not fall asleep independently by the age of 12 weeks. assistance. Such behavioral treatment was shown effec- Our assumption was that although they reported lack tive in prior research for treating existing sleep problems of cooperation, they did receive the intervention and during infancy and is considered the gold standard of therefore ought to be included in the statistical analysis.