Behavioral Insomnia of Childhood: Impact of Parent Education
Condition: Sleep Initiation and Maintenance Disorders
MeSH terms: Sleep Initiation and Maintenance Disorders
Study type: Interventional

Summary: 
      Behavioral Insomnia of Childhood (BIC) is among the most prevalent problem presented to
      pediatricians with a reported occurrence of approximately 30% worldwide.The most widely
      applied treatment strategies for BIC in infants comprise behavioral procedures such as
      unmodified extinction; graduated extinction (ignoring the infant cries with minimal checks),
      or camping out. Unfortunately, breastfeeding is usually considered as an undesirable sleep
      association in these strategies. Moreover, less is known regarding the effects of these
      interventions on breastfeeding outcomes. The cued care is defined as a pattern of care
      characterized by sensible caregiver responsiveness, which meets the need underlying the
      infant's cues in a flexible manner. In this context, POSSUMS has been developed as a cued
      care sleep intervention, which is quite different from the conventional sleep training
      techniques. In the current study, investigators hypothesized that mothers receiving the cued
      care sleep intervention would report less sleep problems in their infants. Secondary outcomes
      included improvement in maternal mood and maintenance of the breastfeeding during the
      observation period.
    

Detailed description: 
      Behavioral Insomnia of Childhood (BIC) is among the most prevalent problem presented to
      pediatricians with a reported occurrence of approximately 30% worldwide.Like all the other
      behavioral problems, sleep problem is defined by the the parents, and influenced by parental
      psychopathology, parenting styles, family dynamics, culturally-based differences in values,
      socio-economic factors, temperament, developmental stage and medical condition of the child.
      Moreover, there is also data suggesting an association of depressed mood among mothers to
      infants with BIC. The most widely applied treatment strategies for BIC in infants comprise
      behavioral procedures such as unmodified extinction; graduated extinction (ignoring the
      infant cries with minimal checks), or camping out. The primary outcomes of these
      interventions include enabling infants to learn to self soothe to sleep, having less
      fragmented night-time sleep and longer night-time sleep periods. Unfortunately, breastfeeding
      is usually considered as an undesirable sleep association in these strategies. Moreover, less
      is known regarding the effects of these interventions on breastfeeding outcomes. Within the
      infant sleep research field, not breastfed but the formula fed baby is usually considered as
      the biological norm. However, since nursing influences both the maternal and infant sleep
      architecture, the outcomes of those behavioral interventions can not be accurately evaluated
      without considering the breastfeeding.

      The cued care is defined as a pattern of care characterized by sensible caregiver
      responsiveness, which meets the need underlying the infant's cues in a flexible manner. In
      this context, POSSUMS has been developed as a cued care sleep intervention, which is quite
      different from the conventional sleep training techniques. This method uses the breast to
      make the baby go back to sleep as quickly as possible as long as the mother is happy with
      breastfeeding at night.

      In the current study, investigators hypothesized that mothers receiving the cued care sleep
      intervention would report less sleep problems in their infants. Secondary outcomes included
      improvement in maternal mood and maintenance of the breastfeeding during the observation
      period.

      The first part of the study was a baseline assessment of sleep problems. Software generated
      random number table was used to randomly allocate subjects to intervention and usual care
      groups. Mother-infant dyads in both groups were reassessed 3 months post intervention.

      225 consecutive mother-infant dyads were assessed for eligibility at Marmara University
      Medical School, well- child outpatient clinic, Istanbul between 01 February 2016 and 15 April
      2016. Seven did not meet the inclusion criteria, and 35 participants declined to participate.
      91 were allocated to usual care, and 92 were allocated to patient education. Twenty five
      participants from the usual care and 1 mother infant dyad from the intervention group were
      lost to follow up and 157were included in the final analysis.
    

Intervention name(s): Educational care derived from POSSUMS
Intervention type(s): Behavioral
Intervention description(s): Intervention group were offered a sleep education session on healthy practices for parent-baby sleep which included information on sleep needs, sleep hygiene, training in strategies to remove obstacles that get in the way of healthy sleep. Information were provided to guide the parent in forming an action plan based on cued care which included aligning the circadian clock with real time, removing the obstacles that get in the way of healthy sleep, physical activity, mindfulness, and relaxation techniques for mothers derived from the POSSUMS approach. However, we could not use Acceptance and Commitment Therapy, because none of the investigators had sufficient training on ACT at the time the study was conducted.
Allocation: Randomized
Intervention model: Parallel Assignment
Masking: None (Open Label)
Primary purpose: Supportive Care
Keywords: sleep, infants, behavioural insomnia, breastfeeding