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Parental Concerns About Infant and Toddler Sleep Assessed by a Mobile App a
b
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Jodi A. Mindell , Erin S. Leichman , Kristina Puzino , Russel Walters e
& Bula Bhullar a
The Children's Hospital of Philadelphia; Saint Joseph's University
b
Kennedy Krieger Institute
c
Lehigh University
d
Johnson & Johnson Consumer Companies, Inc.
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GiantSky Published online: 30 Apr 2014.
To cite this article: Jodi A. Mindell, Erin S. Leichman, Kristina Puzino, Russel Walters & Bula Bhullar (2015) Parental Concerns About Infant and Toddler Sleep Assessed by a Mobile App, Behavioral Sleep Medicine, 13:5, 359-374, DOI: 10.1080/15402002.2014.905475 To link to this article: http://dx.doi.org/10.1080/15402002.2014.905475
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Behavioral Sleep Medicine, 13:359–374, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 1540-2002 print/1540-2010 online DOI: 10.1080/15402002.2014.905475
Parental Concerns About Infant and Toddler Sleep Assessed by a Mobile App Jodi A. Mindell The Children’s Hospital of Philadelphia; Saint Joseph’s University
Erin S. Leichman Kennedy Krieger Institute
Kristina Puzino Lehigh University
Russel Walters Johnson & Johnson Consumer Companies, Inc.
Bula Bhullar GiantSky
The aim of this study was to assess the primary concerns of parents/caregivers regarding their young child’s sleep. A total of 1,287 consecutive sleep-related questions were analyzed from submissions to an Ask the Expert section of a publicly available iPhone-based application for sleep in young children. Questions regarding infants were most likely to be submitted (53.9%), followed by newborns (23.76%) and toddlers (17.8%), with an average age of 10.94 months. The primary concerns regarded night wakings, sleep schedules, and bedtime problems, accounting for almost 85% of all questions. Results align with common concerns noted in epidemiological studies. Understanding the types of concerns for which parents seek advice is beneficial in the continued development of resources for caregivers.
Sleep problems are highly prevalent in young children, occurring in approximately 20–30% of infants and toddlers (Mindell, Kuhn, Lewin, Meltzer, & Sadeh, 2006; Sadeh, Mindell, Luedtke, & Wiegand, 2009). These issues are some of the most common behavioral issues brought to the attention of primary care providers (Cooper, Valleley, Polaha, Begeny, & Evans, 2006). Correspondence should be addressed to Jodi A. Mindell, PhD, Saint Joseph’s University, Department of Psychology, Philadelphia, PA 19131. E-mail: [email protected]
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However, only a median of two hours of training in sleep and sleep disorders is provided in pediatric residency programs (Mindell et al., 2013) and a recent survey of 700 members of the American Academy of Pediatrics found that less than 15% were very confident in their abilities to counsel pediatric patients on sleep issues (Faruqui, Khubchandani, Price, Bolyard, & Reddy, 2011). In the past, additional specialty training for pediatric providers and the integration of psychologists into primary care practices have been utilized to manage these and other behaviorbased issues (Cooper et al., 2006). More recently, telemedicine has been gaining popularity. For example, the Internet has become a widely used resource for parents, and Internet-based interventions have the benefits of being available to a wide audience and the ability to be individualized through algorithms. Internet-based interventions, or “information prescriptions,” have been shown to be efficacious for multiple child health concerns, as well as adult insomnia (Ritterband et al., 2003; Ritterband et al., 2009; Stinson, Wilson, Gill, Yamada, & Holt, 2009). One study found an online algorithm-based pediatric sleep intervention to be highly efficacious, both at posttreatment and at one year follow-up (Mindell et al., 2011a, 2011b). Other creative approaches have also been attempted. One example has been an increase in call-in services. One such service that served two rural primary pediatric practices found that the call-in service that targeted children’s development, behavioral, or emotional concerns was well utilized (Polaha, Volkmer, & Valleley, 2007). Five specific concerns, including daytime wetting, conduct problems, anxiety, sleep, and repetitive behavior, were found to comprise 75% of the calls. Given that children’s sleep problems are often a concern for parents and may be an issue for which they seek information through telemedicine resources, an Ask the Expert function was included in a free smartphone application for sleep in young children. Not only does such a service enable parents to obtain timely and child-specific information, but it also provides information about the specific types of sleep concerns that parents have regarding their young children. Such information is beneficial in the continued development of resources for caregivers that could provide concentrated information on the most common concerns, as well as cover the broad array of issues that parents face. Thus, the aim of this study was to assess real world data regarding the primary concerns of parents/caregivers regarding their young child’s sleep via a mobile application. METHOD Participants Participants included 922 unique users who submitted questions to an Ask the Expert feature of a publicly available iPhone/iPad app for sleep in young children. All questions submitted are sleep-related and the first author individually responds. Parents/caregivers (from here on referred to as “parents”) who submitted questions were primarily mothers (78.42%) with an average age of 26.96 years. A total of 1,287 questions were submitted across the 10-month period. All questions submitted were in English and users were from across the United States and Puerto Rico. Procedure All consecutive sleep-related questions that were submitted across a 10-month period were included in this study. All participants agreed to the inclusion of their question in a research
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study and there were no exclusionary criteria. This study was approved by an Institutional Review Board. No identifying information was collected.
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Analyses Mixed qualitative and quantitative methods were utilized. Consensual qualitative research (CQR) was utilized for the qualitative analyses (Hill et al., 2005; Hill, Thompson, & Williams, 1997). To start, two of the authors (JAM and ESL) collaboratively created an initial codebook (i.e., start list of domains) that defined themes taken from clinically based categories, and used an integrative approach of inductive and deductive organizing frameworks to develop the conceptual codes and subcodes. Initial coding of the first 30 questions was conducted separately by the third author (KP) and two independent research assistants. The team members initially completed the tasks independently and then worked together to develop a consensus version of the codebook. Following this step, an auditor (JAM) examined the domains and core ideas to ensure that the data were accurately represented. If the auditor identified inaccuracies, they were reconsidered by the research team for possible changes. The original codebook of domains was then adjusted to better reflect the nature of the data as emerging themes were identified. For example, the initial codebook included “nursing to sleep” as a subcategory of “bedtime problems.” However, to account for the numerous fathers who submitted questions and many families who bottle feed, the codebook was adjusted to read, “feeding to sleep.” Additionally, the subcategories “confusional arousals” and “sleep terrors” were combined under “parasomnias.” Lastly, due to a multitude of parental concerns regarding sleep training, a “sleep training” theme was added with the following subcategories, “harm to child” and “logistics of sleep training.” To abstract core ideas among the previously established domains, all questions were coded by two independent research assistants, under the supervision of a third author (KP), with regular meetings. In order to ensure that the coders had succinct comprehension of each theme in the codebook, the team regularly convened to determine the level of concordance, to discuss emerging or new themes, and to resolve coding discrepancies. Again, the auditor examined the categories and their frequency to verify their accuracy. Records were kept to denote the themes and theories that emerged over time through examination of the data. The entire team discussed all of the results to verify consensus. All submissions were coded using the final version of the codebook to ensure the integrity and reliability of the coding. Note that a question could be coded within two themes, as often questions addressed multiple issues (e.g., frequent night wakings and concerns about naps). The submitted questions were imported into a qualitative software program, NVivo (Richards, 1999) for thematic coding and content analysis. Agreement rate across the two coders was 97.84%. Means and frequencies were used for demographic information and themes. Chi-square analyses were conducted for comparisons of time of submission and use of pronouns.
RESULTS Participant Demographics Complete demographic data are provided in Table 1. Overall, submissions included an equal number of questions regarding boys (49.0%) and girls (51.0%). The average child age was
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TABLE 1 Demographics
Child sex Boy Girl Child age Newborn (0–2 months) Infant (3–11 months) Toddler (12–36 months) Older child (37C months) User Mother Father Other Age of user 40
Total %
Total n
49.0 51.0
452 470
23.76 53.90 17.79 4.56
219 497 164 42
78.42 4.23 17.35
723 39 160
37.0 24.62 30.2 6.83 1.30
341 227 279 63 12
10.94 months .SD D 23:67/. The majority of users (37.0%) were under 25 years old, between 30 and 34 years old (30.2%), and between 25 and 29 years old (24.62%). Of the 1,287 total submissions, questions by parents of infants (3–11 months; n D 497) were most common (53.90%), followed by those related to newborns (0–2 months; n D 219; 23.76%) and toddlers (n D 164; 12–36 months; 17.79%). Finally, 42 questions were related to older children (> 37 months; 4.56%).
Time of Submission Interestingly, questions were submitted most frequently between 6:00 p.m. and 11:59 p.m. (38.5%), followed by 12:00 p.m. to 6:00 p.m. (24.0%), 6:00 a.m. to 11:59 a.m. (19.3%), and 12:00 a.m. to 5:59 a.m. (16.4%), 2 D 151:19, p < :001 (see Figure 1). There were significant differences for users age and child age based on the time of question submission. Those users who submitted questions overnight, from 12:00 a.m. to 5:59 a.m., were younger (M D 25:92 years) than those who submitted at other times of the day (M D 26:68 to 27.96), F(3,1258) D 4.21, p D :006. In terms of child age, questions submitted in the evening (mean age D 12.02 months) and overnight .M D 11:98/ were about older children compared to those submitted in the morning .M D 7:17/ and afternoon .M D 11:98/, F(3,1249) D 3.23, p D :022: There were no differences in time of day of submission for mothers compared to fathers, 2 D 3:86, p D :277.
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FIGURE 1 Percent of questions by time of day.
Themes A total of nine themes emerged around parental concerns and questions about young children’s sleep. Themes and representative questions are summarized below and in Table 2. The prevalence of questions for each theme and subtheme are provided in Tables 3 and 4. Night wakings. Night wakings were the most common issue addressed by parents, with 29.53% of total questions coded as this theme. Parental concerns about night wakings were coded into three primary subthemes, including general questions about frequent night wakings (69.47%), issues with feeding back to sleep after a night waking (25.53%), and early morning awakenings (5.53%). General questions about night wakings included such questions as, “He has been waking at night and refusing to go back to sleep. Despite the fact that he is able to put himself to sleep when initially going to bed, he is unable to/refuses to when he wakes at night.” Feeding back to sleep questions focused on the child nursing or being bottle-fed back to sleep during the night. For example, “How can I get my 18-month-old to sleep without a bottle and return to sleep without a bottle?” In addition, parental concerns about night wakings included early morning awakening, in which the child wakes for the day earlier than the parent desires. For example, “All of a sudden my son is waking at 5:00 a.m. when he used to wake at 6:30; how can I change his wake time?” Schedule. The second most common concern related to the young children’s sleep schedules, with 27.89% of total questions coded as this theme. Within the general theme regarding scheduling issues, parental concerns about children’s sleep schedule emphasized naps (50.70%), sleep duration (24.79%), sleep schedule (20.05%), feeding schedule (12.53%), and morning wake time (0.84%). Many parents asked questions about naps, which included the frequency, duration, resistance, or location of intentional daytime sleeping: “How many and how long should naps be during the day?” and “What are good sleep and eat routines? And how
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TABLE 2 Parental Concerns and Questions Regarding Young Children’s Sleep Themes
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1. Night wakings
2. Schedule
3. Bedtime problems 4. Sleep environment
5. Sleep training
6. Parasomnia 7. Health-related sleep issues 8. Sleep-disordered breathing 9. Other sleep issues
Representative Quotes “How can I get her to sleep through the night? She wakes up every 2 hours or so, even if I sleep next to her. I tried the CIO method but then she cries in her sleep and still wakes up from time to time. What should I try next?” “How much sleep does a 2-month-old require? My son seems to want frequent naps during the day. At least 3 to 4 naps, sometimes 1 to 2 hours long. Is this normal?” “My 4-year-old is afraid, wants the light on, wants us to come back in the room, etc. He will yell for us or be really loud so we’ll know he is still awake.” “She will nap in her crib most of the time but at night she loves her swing and won’t either go down in the crib or back in her crib after the middle of the night feeding.” “I would like to know how to put my daughter to bed after her routine that does not involve her crying it out. I am not comfortable doing this and if I put her to bed after her routine she just cries. Admittedly, I have never let her cry for more than 2 or 3 minutes, but by then she is screaming (hands balled into fists, face bright red, and tears)!” “My son often wakes up through the night crying frantically as if he were having a bad dream. Is there anything I can do to stop this from happening?” “How can I help my baby sleep better when she has a cough with phlegm?” “My daughter is 7 months old now, and she breathes really hard when she naps or sleeps throughout the night. Is this normal?” “My daughter wiggles so much at night! Is that normal? We do not wrap her in a blanket like the hospital. Will she ever stop wiggling so much and does this mess with her sleep?”
TABLE 3 Prevalence of Themes Age group
Gender
Theme
Total Sample
Newborn
Infant
Toddler
Older Child
Female
Male
1. 2. 3. 4. 5. 6. 7. 8. 9.
29.53% 27.89% 26.65% 11.42% 9.40% 7.69% 4.51% 0.54% 2.02%
19.96% 27.44% 29.51% 7.99% 4.45% 1.52% 5.41% 0.33% 3.39%
33.51% 18.98% 20.28% 8.86% 10.83% 1.35% 3.97% 0.22% 1.99%
31.35% 15.92% 22.32% 9.97% 10.27% 4.18% 2.15% 3.86% 0.00%
17.63% 4.61% 28.17% 23.45% 4.12% 13.67% 4.39% 0.77% 3.19%
27.12% 21.86% 23.61% 7.45% 11.86% 2.08% 3.24% 1.21% 1.57%
33.12% 18.02% 21.63% 10.97% 6.60% 2.01% 4.88% 0.24% 2.54%
Night wakings Schedule Bedtime problems Sleep environment Sleep training Parasomnias Health-related sleep issues Sleep-disordered breathing Other sleep issues
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Sleep environment
Bedtime problems
Schedule/general sleep
Night wakings
Themes
Bedtime sleep resistance/struggle Adult presence to fall asleep Bedtime routine Bedtime Transition to sleeping independently Feeding to sleep Bedtime fears
Naps Sleep schedule Sleep duration Feeding schedule Morning wake time
1. Transition from co-sleeping to own bed or room 2. General sleep environment 3. Sleep position 4. Pacifier 5. Swaddling 6. Crib safety 7. Cosleeping safety 8. Transition from crib to bed
1. 2. 3. 4. 5. 6. 7.
1. 2. 3. 4. 5.
1. Night wakings 2. Feeding back to sleep 3. Early morning waking
Subthemes
25.85% 20.41% 17.00% 11.56% 11.56% 8.84% 4.76% 2.72%
2.33% 1.94% 1.32% 1.32% 1.01% 0.54% 0.31%
30.61% 22.45% 15.16% 15.45% 11.66% 7.58% 1.75%
50.70% 20.05% 24.79% 12.53% 0.84%
69.47% 25.53% 5.53%
Total Sample % Within Themes
29.53% 20.51% 7.54% 1.63% 27.89% 14.14% 5.60% 5.36% 3.50% 0.23% 26.65% 8.16% 6.00% 4.27% 4.12% 3.10% 2.49% 0.47% 11.42% 2.95%
Total Sample % Overall Sample
TABLE 4 Prevalence of Themes
35.63% 13.65% 10.27% 3.86% 6.04% 16.43% 0.00%
14.13%
22.95% 22.36% 23.45% 9.82% 16.27% 4.87% 0.28%
36.49% 34.73% 12.56% 16.22% 0.00%
64.09% 29.50% 6.41%
Newborn
25.57% 17.25% 8.54% 14.57% 10.67% 6.12% 0.00%
17.27%
35.47% 11.67% 19.65% 9.75% 14.3% 8.59% 0.57%
56.8% 22.32% 7.06% 11.55% 2.27%
63.91% 28.58% 7.50%
Infant
12.02% 1.80% 6.62% 0.00% 0.00% 0.00% 2.93%
76.63%
25.83% 16.03% 9.51% 10.33% 16.26% 15.07% 6.98%
41.16% 33.32% 20.98% 3.68% 0.87%
70.56% 21.4% 8.04%
Toddler
Age Group
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(continued )
3.10% 0.00% 0.00% 0.00% 0.00% 6.65% 5.32%
84.92%
8.42% 22.61% 17.82% 13.53% 21.62% 6.27% 9.74%
22.50% 33.33% 44.17% 0.00% 0.00%
100.00% 0.00% 0.00%
Older Child
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Other sleep issues
Sleep-disordered breathing
Health-related sleep issues
Parasomnias
Sleep training
Themes
Teething Behavioral Health Colic Reflux Coughing/wheezing Vomiting Prematurity
Confusional arousal/sleep terror Nightmare Sleep talking Toilet training Nocturnal enuresis Sleepwalking
1. Restless 2. Family situation 3. Limb Movements
1. 2. 3. 4. 5. 6. 7.
1. 2. 3. 4. 5. 6.
1. Logistics of sleep training 2. Harm to child
Subthemes
2.02% 1.01% 0.54% 0.39%
9.40% 8.86% 0.62% 7.69% 1.70% 0.85% 0.54% 0.39% 0.23% 0.16% 4.51% 1.01% 0.47% 0.39% 0.39% 0.23% 0.23% 0.16% 0.54%
Total Sample % Overall Sample
TABLE 4 (Continued)
50.0% 26.92% 19.23%
—
22.41% 10.34% 8.62% 8.62% 5.17% 5.17% 3.45%
22.22% 11.11% 7.07% 5.05% 3.03% 2.02%
94.21% 6.61%
Total Sample % Within Themes
38.71% 30.72% 30.57%
—
0.00% 14.87% 38.59% 28.46% 0.00% 3.59% 14.49%
0.00% 8.90% 84.32% 3.39% 3.39% 0.00%
100% 0.00%
Newborn
49.36% 5.62% 45.02%
—
64.28% 13.1% 2.93% 4.44% 6.16% 2.58% 6.51%
49.93% 13.24% 27.17% 2.62% 3.72% 3.31%
93.83% 6.17%
Infant
0.00% 0.00% 0.00%
—
29.84% 41.36% 0.00% 0.00% 6.28% 22.51% 0.00%
43.57% 32.44% 2.11% 12.67% 9.21% 0.00%
54.02% 45.98%
Toddler
Age Group
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34.09% 31.82% 34.09%
—
0.00% 89.89% 0.00% 0.00% 0.00% 0.00% 0.00%
26.84% 32.27% 0.00% 17.25% 23.64% 0.00%
100% 0.00%
Older Child
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many hours should babies sleep during the day?” Questions regarding sleep duration involved inquiries about the appropriate length of time a child should sleep, such as, “How many hours all together with night sleep and daytime naps should a 23-month-old be getting? My son sleeps between 9 and 10 hours a night and takes a nap for 2–3 hours during the day. Is this average?” With respect to feeding schedules, parents discussed issues pertaining to the timing of feedings as related to sleep: “Does feeding them a bottle earlier in the bedtime routine cause them to wake earlier for feeding?” Bedtime problems. Parental concerns about bedtime (26.65% of all questions) focused on bedtime struggles/resistance (30.61% within this category), adult presence to fall asleep (22.45%), bedtime routines (15.16%), bedtimes (15.45%), and feeding to sleep (7.58%). These questions addressed issues such as the time of day the child goes to sleep, activities families do prior to bedtime (e.g., taking a bath, reading a story), and child resistance (e.g., fights sleep at bedtime). Furthermore, parents expressed concern regarding needing an adult present to fall asleep and transitioning to sleeping independently. Specifically, when parents asked questions pertaining to adult presence, they stated their child needed to be held, rocked, patted, or an adult needed to be in the room in order for the child to fall asleep: “My 3-month-old will not sleep on her own. What can I do? As soon as I take her out of my arms, she wakes up and cries until picked up.” Parental concerns of transition from cosleeping to sleeping independently were related to how or when to transition a young child: “I am trying to break the habit of cosleeping. My daughter is a big 7-month-old, about the size of babies twice her age, so it’s getting a little crowded. She stands and plays in her crib or screams her head off. What should I do? Will she lie down eventually if I try the cry it out method?” Sleep environment. Approximately 1 out of 10 submitted questions (11.42% of all questions) regarded the sleep environment. The most commonly asked questions within this theme were about the specifics of transitioning the child to sleeping in his/her own crib/bed/room (25.85%; e.g., “My son wakes up a lot at night. Recently I started bringing him to my bed where he sleeps so much better. I’m not completely opposed to cosleeping, but I get up at 5:00 a.m., which means so does he. Any ideas on helping him sleep better all night and in his crib?”). Also asked were questions about the more general sleep environment (20.41%), crib safety (8.84%), cosleeping safety (4.76%), and transitioning from a crib to a bed (2.72%). General questions about the sleep environment included such issues as room temperature and bed clothing, as well as sleep position (e.g., “Is it okay for my baby to sleep on her stomach?”), swaddling, and pacifier questions. In addition, parental concerns regarding crib safety addressed the safety of having items such as bedding or pillows in a crib, as well as climbing out of a crib. Swaddling and pacifier concerns specifically addressed their use or discontinuing: “My son is still swaddled at night and today he rolled over for the first time. How do I get him to sleep without swaddling?” Sleep training. Parental concerns regarding sleep training (9.40% of all questions) emphasized the logistics of sleep training (94.21%) and the possibility that sleep training would harm their child (6.61%). Questions were included in this category if the parent directly utilized the phrase “sleep training,” if they asked in more general terms about helping babies learn to
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fall asleep on their own, or if they referred to “crying it out.” Very few questions related to parental worry about using crying it out methods: “Should I be concerned about increased cortisol levels for such a young infant? At what level of intensity or duration of crying would you start to become concerned about stress hormones?” Instead, most questions were more general about the logistics of implementing sleep training: “We are doing CIO with checks every 15 minutes. Is it okay to give her the pacifier during the checks? It works so well to calm her down and get her back to sleep.” Parasomnias. For these questions (7.69% of all questions), parents addressed various types of parasomnias, including nightmares (11.11%), sleepwalking (2.02%), sleep talking (7.07%), confusional arousals/sleep terrors (22.22%), nocturnal enuresis (3.03%), and toilet training (5.05%). In regard to confusional arousals/sleep terrors, parental concerns were related to young children screaming, crying, or whining, and not being completely awake (e.g., “My son often wakes up through the night crying frantically as if he was having a bad dream. Is there anything I can do to stop this from happening?”). Additionally, questions about confusional arousals included seeming disoriented while sleeping overnight or during naps. Toilet training issues were related to wearing a diaper or pull-up at night or how to manage toilet training through the night. Health-related sleep issues. This theme included health issues that were related to sleep concerns (4.51% of all questions). Parents were primarily concerned about sleep issues related to teething (22.41%), as well as reflux (8.62%), colic (8.62%), coughing/wheezing (5.17%), vomiting (5.17%), prematurity (3.45%), and behavioral health (10.34%; e.g., sleep issues related to child ADHD, depression, or anxiety). For example, “My daughter’s family has moved into a new home and they have a new baby due soon. The big sister has gone from sleeping all night to waking several times a night. We’re sure it’s anxiety from all the new things, but any suggestions?” Sleep-disordered breathing. Concerns about sleep-disordered breathing (0.54% of all questions) were mentioned infrequently. These parental concerns were related to snoring, noisy breathing, or pauses in breathing: “My baby wakes up when I put her down to her bassinet no matter how long I hold her. Her breathing also sounds like she has mucus in her throat. She just started this week and she makes noises while asleep too.” Other sleep issues. Finally, a few questions addressed other sleep issues (2.02%), which were not captured within the previously discussed themes. These few questions and concerns emphasized restlessness (50.00%), limb movements (19.23%), or family situations (26.92%). When parents mentioned limb movements, it was usually related to sudden arm or leg movements during sleep: “Ross thrashes around a lot when he sleeps. This causes him to wake and scream. This in turn will keep him up for up to 2 hours at a time. How should I control his rolling and make his crib safer to sleep in?” Concerns about family situations often focused on the presence of a sibling in the family or bedroom: “I have twin baby boys. I have been having a hard time getting them down without rocking them to sleep. I try to put them down but they seem to wake each other up. Any tips on how to deal with twin sleeping?”
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Gender and Age Differences in Themes Differences in prevalence of themes based on child gender and age are presented in Table 3. Overall, there were minimal differences in themes for boys compared to girls, although twice as many questions regarding sleep training in girls came in as for boys. As expected, differences were found across age groups. In looking at the general themes, questions regarding newborns were primarily about bedtime problems (29.51%) and newborns’ sleep schedules (27.44%), with night wakings also a common concern (19.96%). In contrast, questions submitted by parents of infants and toddlers were most concerned about night wakings (33.51% and 31.35%, respectively). In older children, bedtime problems (28.17%) and the sleep environment (23.45%), primarily transitioning to sleeping in own room or to a bed, were the focus. Night wakings, however, continued to be an issue for some parents (17.63%). In order to enumerate the differences among age groups, the prevalence of subthemes was explored (see Table 4). Across all age groups, questions about night wakings were primarily focused on general night waking concerns, such as the frequency and duration of night wakings. Feeding back to sleep was a consistent concern from birth to three years, but not a concern in older children. Within the category of sleep schedule, parents of newborns were equally concerned about naps and general sleep schedule, whereas parents of both infants and toddlers primarily asked about naps, with general sleep schedule concerns second in likelihood. Parents of older children who asked questions about schedule/general sleep focused on sleep duration. In the area of bedtime problems, questions were fairly consistent across the ages, with parents of newborns focused on adult presence to fall asleep, bedtime routine, and bedtime sleep resistance/struggle, whereas parents of infants and toddlers emphasized bedtime sleep resistance/struggle. In addition, parents of older children focused on adult presence to fall asleep, transition to sleeping independently, and bedtime routines. Questions regarding sleep environment shifted from few parents of newborns asking about transitioning from cosleeping to independent sleeping to almost all questions appearing in this category for parents of toddlers and older children. As expected, sleep position and swaddling were no longer a concern after infancy, nor were general crib safety and cosleeping safety. Finally, within health-related sleep issues, parents of newborns focused on colic and reflux, while parents of infants emphasized teething. Parents of toddlers and older children who asked questions about health-related sleep issues emphasized behavioral health.
Parent Differences in Themes Differences in prevalence of themes based on mothers compared to fathers are presented in Figure 2. Overall, mothers asked more questions about night wakings, bedtime problems, and schedules than other topics. Similarly, fathers asked more questions about night wakings and bedtime problems than other topics. Although the proportions of questions asked by mothers and fathers were quite similar in that the majority of questions asked were about night wakings, bedtime problems, and schedules, mothers asked somewhat more questions (proportionally) about schedules and sleep training than did fathers. Almost no fathers asked about sleep training (1.44%) compared to mothers (9.37%).
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FIGURE 2
Theme by user.
Word Prevalence A word cloud created from the text of the original submissions is presented in Figure 3. It provides a representation of the most common words appearing across all submitted questions. The size of the word represents how frequently it was used. As expected, the word sleep appears the most often. The next two most frequently occurring words are night and wakes, which is consistent with the dominant theme of night wakings.
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Word cloud representation of most frequently occurring words.
FIGURE 4
Pronoun use in questions submitted.
Finally, pronoun choice by user was established, in regard to their use of “I” versus “he/she/son/daughter.” The results are represented in the Venn diagram in Figure 4. As expected, of those questions that included any of these pronouns, the majority included both in their questions (n D 507; 56.6%). If the question only included one of these terms, respondents were almost twice as likely to use the term “he/she/son/daughter” only (n D 262; 29.2%) as to use “I” only (n D 127; 14.2%). There were no differences in fathers’ and mothers’ choice of pronouns, 2 D :98, p D :61.
DISCUSSION This study found that parents/caregivers are most concerned about bedtime problems, night wakings, and sleep schedule issues with their infants and toddlers, accounting for almost 85%
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of all questions submitted. More specifically, about the problem of night wakings in general was the number one most common concern of parents, accounting for 21% of all questions, followed by questions about naps (14%). Issues associated with feeding back to sleep during the night and bedtime resistance/struggles each comprised 8% of all submissions. The rest of all submissions covered a broad array of topics, from questions about swaddling to bedwetting. Overall, there were no differences in questions asked based on the gender of the child. This finding is consistent with past research that has found limited, if any, gender differences in sleep in young children (Mindell, Meltzer, Carskadon, & Chervin, 2009; Sadeh et al., 2009). Not surprisingly, however, the types of concerns changed across this developmental period, with parents of newborns equally concerned about their child’s night wakings, bedtime issues, and general sleep schedule. In contrast, parents of infants and toddlers were most likely to ask questions about night wakings, which comprised one third of all questions submitted. Finally, parents of older children were most concerned about transitioning from a crib to a bed and having their child transition to sleeping independently. Not surprisingly, parents of newborns and infants had concerns about such issues as their child’s sleep position, swaddling, and pacifiers, but these types of questions were not asked by parents of toddlers or older children. This differential lends support to the validity of these data regarding the concerns that parents have at different developmental stages. Interestingly, there were few questions about more medically based sleep issues, especially sleep-disordered breathing. Only 0.5% of questions submitted were related to such issues as snoring or noisy breathing, although one study indicated that approximately 9% of infants experience habitual snoring (Piteo et al., 2011), and a second study found prevalence rates of “always” snoring ranging from 3.6% at 1.5 years to a peak of 7.7% at 3.5 years, and habitual snoring of 9.6% at 1.5 years to 21% at 3.5 years (Bonuck et al., 2011). This result supports the need for increased education of parents about a broad array of sleep issues, especially to increase awareness of symptoms of sleep-disordered breathing. These results also provide practitioners and researchers with an understanding of what concerns are most common in parents in real-world settings, rather than what is known from studies that use forced-choice questions and limited lists of concerns that parents can endorse. More in-depth analyses enabled assessment of nuances in parental concerns. For example, we found that although the primary concerns of mothers and fathers were similar, mothers are more likely to ask questions about sleep training especially, as well as sleep schedules. This differential may reflect differences in parental roles, with mothers possibly more likely to be involved in sleep training and family schedules, or more concerned about making changes. Previous studies have found differences in paternal and maternal cognitions about sleep in young children (Sadeh, Flint-Ofir, Tirosh, & Tikotzky, 2007), which may be further reflected in our findings. In addition, the analysis of pronoun use in questions submitted seems to indicate that parents are more likely to attribute the sleep-related problem (and potentially the solution) to the child rather than anticipating the need to change their own behavior in order to rectify the sleep-related problem. These findings are similarly supported by research on parental cognitions about sleep, with previous research indicating that maternal cognitions related to concerns about infants’ distress at night are associated with more disturbed sleep, while maternal cognitions emphasizing the importance of limit-setting are associated with more consolidated sleep (Morrell, 1999; Sadeh et al., 2007; Tikotzky & Sadeh, 2009). The use of “I” may reflect increased beliefs about internal control regarding their child’s sleep, whereas the
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use of “he/she/son/daughter” may indicate cognitions that attribute sleep issues as controlled more by the child. Future research is needed to further explore these subtle nuances in language and whether they are indicative of cognitions that impact sleep and sleep issues. Although not a primary aim of this study, it was interesting to note that almost half of all questions submitted by users occurred between 6:00 p.m. and 6:00 a.m., when primary care providers are not typically accessible. Parents may have submitted their questions during this period because it was when they may have been more likely to be utilizing technology or it may be when questions about sleep are most likely to arise. The high utilization of this service, especially during off-peak hours, supports parental interest in accessible information and advice throughout the day and night (Siemer, Fogel, & Van Voorhees, 2011). The primary limitation of this study was that the sample is likely quite homogenous, as it only included parents who were iPhone/iPad users and those who sought out an app related to sleep in young children. However, studies show that 81% of U.S. adults aged 25–34 (the primary study demographic) own a smartphone. Furthermore, while smartphone ownership increases with income and education, the effect of income is small; for people with incomes below $30,000, smartphone ownership is 77% as compared to 90% for incomes over $75,000. Note, though, that iPhone ownership does tend to skew more sharply toward high income and more education than the Android platform (Smith, 2013). In addition, the parents submitting questions represented a diverse age group and the sample studied represents the parents who will most likely utilize telemedicine resources. Further, this app and service were publicly available and thus free to be utilized by parents of any socioeconomic status as long as they had access to an iPhone or iPad. Finally, a unique aspect of this study is that this is nonclinical real world data (RWD) regarding parental concerns. Overall, this study found that parents are most concerned about night wakings in young children, as well as bedtime problems and sleep schedules. Knowledge of the primary concerns of parents can help guide health care practitioners in the presentation of the most applicable prevention and education efforts in their interactions of families and with broader education initiatives. Furthermore, a need continues for the development and availability of telemedicine resources for parents, including Internet-based resources, as well as app-based and other technologically available resources.
ACKNOWLEDGMENTS This study was sponsored by Johnson & Johnson Consumer Consumer Companies, Inc. Dr. Mindell has served as a consultant and speaker for Johnson & Johnson. Dr. Leichman and Mr. Bhullar have served as consultants for Johnson & Johnson. Dr. Walters is an employee of Johnson & Johnson.
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Cooper, S., Valleley, R. J., Polaha, J., Begeny, J., & Evans, J. H. (2006). Running out of time: Physician management of behavioral health concerns in rural pediatric primary care. Pediatrics, 118(1), e132–138. Faruqui, F., Khubchandani, J., Price, J. H., Bolyard, D., & Reddy, R. (2011). Sleep disorders in children: A national assessment of primary care pediatrician practices and perceptions. Pediatrics, 128(3), 539–546. Hill, C. E., Knox, S., Thompson, B. J., Williams, E. N., Hess, S. A., & Ladany, N. (2005). Consensual qualitative research: An update. Journal of Counseling Psychology, 52(2), 196–205. Hill, C. E., Thompson, B. J., & Williams, E. N. (1997). A guide to conducting consensual qualitative research. The Counseling Psychologist, 25(4), 517–572. Mindell, J. A., Bartle, A., Ahn, Y., Ramamurthy, M. B., Huong, H. T. D., Kohyama, J., : : : Goh, D. Y. T. (2013). Sleep education in pediatric residency programs: a cross-cultural look. BMC Res Notes, 6, 130. Mindell, J. A., Du Mond, C. E., Sadeh, A., Telofski, L. S., Kulkarni, N., & Gunn, E. (2011a). Efficacy of an internetbased intervention for infant and toddler sleep disturbances. Sleep, 34(4), 451–458. Mindell, J. A., Du Mond, C. E., Sadeh, A., Telofski, L. S., Kulkarni, N., & Gunn, E. (2011b). Long-term efficacy of an internet-based intervention for infant and toddler sleep disturbances: One year follow-up. Journal of Clinical Sleep Medicine, 7(5), 507–511. Mindell, J. A., Kuhn, B., Lewin, D. S., Meltzer, L J., & Sadeh, A. (2006). Behavioral treatment of bedtime problems and night wakings in infants and young children. Sleep, 29(10), 1263–1276. Mindell, J. A., Meltzer, L. J., Carskadon, M. A., & Chervin, R. D. (2009). Developmental aspects of sleep hygiene: Findings from the 2004 National Sleep Foundation Sleep in America Poll. Sleep Medicine, 10(7), 771–779. Morrell, J. M. (1999). The role of maternal cognitions in infant sleep problems as assessed by a new instrument, the maternal cognitions about infant sleep questionnaire. Journal of Child Psychology and Psychiatry, 40(2), 247–258. Piteo, A. M., Lushington, K., Roberts, R. M., van den Heuvel, C. J., Nettelbeck, T., Kohler, M. J., : : : Kennedy, J. D. (2011). Prevalence of snoring and associated factors in infancy. Sleep Medicine, 12(8), 787–792. Polaha, J., Volkmer, A., & Valleley, R. J. P. (2007). A call-in service to address parent concerns about child behavior in rural primary care. Families, Systems & Health, 25(3), 333. Ritterband, L. M., Gonder-Frederick, L., Cox, D., Clifton, A. D., West, R. W., & Borowitz, S. (2003). Internet interventions: In review, in use, and into the future. Professional Psychology: Research and Practice, 34(5), 527– 534. Ritterband, L. M., Thorndike, F. P., Gonder-Frederick, L. A., Magee, J. C., Bailey, E. T., Saylor, D. K., & Morin, C. M. (2009). Efficacy of an Internet-based behavioral intervention for adults with insomnia. Archives of General Psychiatry, 66(7), 692–698. Sadeh, A., Flint-Ofir, E., Tirosh, T., & Tikotzky, L. (2007). Infant sleep and parental sleep-related cognitions. Journal of Family Psychology, 21(1), 74–87. Sadeh, A., Mindell, J. A., Luedtke, K., & Wiegand, B. (2009). Sleep and sleep ecology in the first 3 years: A web-based study. Journal of Sleep Research, 18(1), 60–73. Siemer, C. P., Fogel, J., & Van Voorhees, B. W. (2011). Telemental health and web-based applications in children and adolescents. Child and Adolescent Psychiatric Clinics of North America, 20(1), 135–153. Smith, A. (2013). Smartphone ownership: 2013 update. Pew Internet & American Life Project. Washington, DC: Pew Research Center. Stinson, J., Wilson, R., Gill, N., Yamada, J., & Holt, J. (2009). A systematic review of internet-based self-management interventions for youth with health conditions. Journal of Pediatric Psychology, 34(5), 495–510. Tikotzky, L., & Sadeh, A. (2009). Maternal sleep-related cognitions and infant sleep: A longitudinal study from pregnancy through the first year. Child Development, 80, 860–874.
Behavioral Sleep Medicine Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/hbsm20
Parental Concerns About Infant and Toddler Sleep Assessed by a Mobile App a
b
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Jodi A. Mindell , Erin S. Leichman , Kristina Puzino , Russel Walters e
& Bula Bhullar a
The Children's Hospital of Philadelphia; Saint Joseph's University
b
Kennedy Krieger Institute
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Lehigh University
d
Johnson & Johnson Consumer Companies, Inc.
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GiantSky Published online: 30 Apr 2014.
To cite this article: Jodi A. Mindell, Erin S. Leichman, Kristina Puzino, Russel Walters & Bula Bhullar (2015) Parental Concerns About Infant and Toddler Sleep Assessed by a Mobile App, Behavioral Sleep Medicine, 13:5, 359-374, DOI: 10.1080/15402002.2014.905475 To link to this article: http://dx.doi.org/10.1080/15402002.2014.905475
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Behavioral Sleep Medicine, 13:359–374, 2015 Copyright © Taylor & Francis Group, LLC ISSN: 1540-2002 print/1540-2010 online DOI: 10.1080/15402002.2014.905475
Parental Concerns About Infant and Toddler Sleep Assessed by a Mobile App Jodi A. Mindell The Children’s Hospital of Philadelphia; Saint Joseph’s University
Erin S. Leichman Kennedy Krieger Institute
Kristina Puzino Lehigh University
Russel Walters Johnson & Johnson Consumer Companies, Inc.
Bula Bhullar GiantSky
The aim of this study was to assess the primary concerns of parents/caregivers regarding their young child’s sleep. A total of 1,287 consecutive sleep-related questions were analyzed from submissions to an Ask the Expert section of a publicly available iPhone-based application for sleep in young children. Questions regarding infants were most likely to be submitted (53.9%), followed by newborns (23.76%) and toddlers (17.8%), with an average age of 10.94 months. The primary concerns regarded night wakings, sleep schedules, and bedtime problems, accounting for almost 85% of all questions. Results align with common concerns noted in epidemiological studies. Understanding the types of concerns for which parents seek advice is beneficial in the continued development of resources for caregivers.
Sleep problems are highly prevalent in young children, occurring in approximately 20–30% of infants and toddlers (Mindell, Kuhn, Lewin, Meltzer, & Sadeh, 2006; Sadeh, Mindell, Luedtke, & Wiegand, 2009). These issues are some of the most common behavioral issues brought to the attention of primary care providers (Cooper, Valleley, Polaha, Begeny, & Evans, 2006). Correspondence should be addressed to Jodi A. Mindell, PhD, Saint Joseph’s University, Department of Psychology, Philadelphia, PA 19131. E-mail: [email protected]
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However, only a median of two hours of training in sleep and sleep disorders is provided in pediatric residency programs (Mindell et al., 2013) and a recent survey of 700 members of the American Academy of Pediatrics found that less than 15% were very confident in their abilities to counsel pediatric patients on sleep issues (Faruqui, Khubchandani, Price, Bolyard, & Reddy, 2011). In the past, additional specialty training for pediatric providers and the integration of psychologists into primary care practices have been utilized to manage these and other behaviorbased issues (Cooper et al., 2006). More recently, telemedicine has been gaining popularity. For example, the Internet has become a widely used resource for parents, and Internet-based interventions have the benefits of being available to a wide audience and the ability to be individualized through algorithms. Internet-based interventions, or “information prescriptions,” have been shown to be efficacious for multiple child health concerns, as well as adult insomnia (Ritterband et al., 2003; Ritterband et al., 2009; Stinson, Wilson, Gill, Yamada, & Holt, 2009). One study found an online algorithm-based pediatric sleep intervention to be highly efficacious, both at posttreatment and at one year follow-up (Mindell et al., 2011a, 2011b). Other creative approaches have also been attempted. One example has been an increase in call-in services. One such service that served two rural primary pediatric practices found that the call-in service that targeted children’s development, behavioral, or emotional concerns was well utilized (Polaha, Volkmer, & Valleley, 2007). Five specific concerns, including daytime wetting, conduct problems, anxiety, sleep, and repetitive behavior, were found to comprise 75% of the calls. Given that children’s sleep problems are often a concern for parents and may be an issue for which they seek information through telemedicine resources, an Ask the Expert function was included in a free smartphone application for sleep in young children. Not only does such a service enable parents to obtain timely and child-specific information, but it also provides information about the specific types of sleep concerns that parents have regarding their young children. Such information is beneficial in the continued development of resources for caregivers that could provide concentrated information on the most common concerns, as well as cover the broad array of issues that parents face. Thus, the aim of this study was to assess real world data regarding the primary concerns of parents/caregivers regarding their young child’s sleep via a mobile application. METHOD Participants Participants included 922 unique users who submitted questions to an Ask the Expert feature of a publicly available iPhone/iPad app for sleep in young children. All questions submitted are sleep-related and the first author individually responds. Parents/caregivers (from here on referred to as “parents”) who submitted questions were primarily mothers (78.42%) with an average age of 26.96 years. A total of 1,287 questions were submitted across the 10-month period. All questions submitted were in English and users were from across the United States and Puerto Rico. Procedure All consecutive sleep-related questions that were submitted across a 10-month period were included in this study. All participants agreed to the inclusion of their question in a research
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study and there were no exclusionary criteria. This study was approved by an Institutional Review Board. No identifying information was collected.
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Analyses Mixed qualitative and quantitative methods were utilized. Consensual qualitative research (CQR) was utilized for the qualitative analyses (Hill et al., 2005; Hill, Thompson, & Williams, 1997). To start, two of the authors (JAM and ESL) collaboratively created an initial codebook (i.e., start list of domains) that defined themes taken from clinically based categories, and used an integrative approach of inductive and deductive organizing frameworks to develop the conceptual codes and subcodes. Initial coding of the first 30 questions was conducted separately by the third author (KP) and two independent research assistants. The team members initially completed the tasks independently and then worked together to develop a consensus version of the codebook. Following this step, an auditor (JAM) examined the domains and core ideas to ensure that the data were accurately represented. If the auditor identified inaccuracies, they were reconsidered by the research team for possible changes. The original codebook of domains was then adjusted to better reflect the nature of the data as emerging themes were identified. For example, the initial codebook included “nursing to sleep” as a subcategory of “bedtime problems.” However, to account for the numerous fathers who submitted questions and many families who bottle feed, the codebook was adjusted to read, “feeding to sleep.” Additionally, the subcategories “confusional arousals” and “sleep terrors” were combined under “parasomnias.” Lastly, due to a multitude of parental concerns regarding sleep training, a “sleep training” theme was added with the following subcategories, “harm to child” and “logistics of sleep training.” To abstract core ideas among the previously established domains, all questions were coded by two independent research assistants, under the supervision of a third author (KP), with regular meetings. In order to ensure that the coders had succinct comprehension of each theme in the codebook, the team regularly convened to determine the level of concordance, to discuss emerging or new themes, and to resolve coding discrepancies. Again, the auditor examined the categories and their frequency to verify their accuracy. Records were kept to denote the themes and theories that emerged over time through examination of the data. The entire team discussed all of the results to verify consensus. All submissions were coded using the final version of the codebook to ensure the integrity and reliability of the coding. Note that a question could be coded within two themes, as often questions addressed multiple issues (e.g., frequent night wakings and concerns about naps). The submitted questions were imported into a qualitative software program, NVivo (Richards, 1999) for thematic coding and content analysis. Agreement rate across the two coders was 97.84%. Means and frequencies were used for demographic information and themes. Chi-square analyses were conducted for comparisons of time of submission and use of pronouns.
RESULTS Participant Demographics Complete demographic data are provided in Table 1. Overall, submissions included an equal number of questions regarding boys (49.0%) and girls (51.0%). The average child age was
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TABLE 1 Demographics
Child sex Boy Girl Child age Newborn (0–2 months) Infant (3–11 months) Toddler (12–36 months) Older child (37C months) User Mother Father Other Age of user 40
Total %
Total n
49.0 51.0
452 470
23.76 53.90 17.79 4.56
219 497 164 42
78.42 4.23 17.35
723 39 160
37.0 24.62 30.2 6.83 1.30
341 227 279 63 12
10.94 months .SD D 23:67/. The majority of users (37.0%) were under 25 years old, between 30 and 34 years old (30.2%), and between 25 and 29 years old (24.62%). Of the 1,287 total submissions, questions by parents of infants (3–11 months; n D 497) were most common (53.90%), followed by those related to newborns (0–2 months; n D 219; 23.76%) and toddlers (n D 164; 12–36 months; 17.79%). Finally, 42 questions were related to older children (> 37 months; 4.56%).
Time of Submission Interestingly, questions were submitted most frequently between 6:00 p.m. and 11:59 p.m. (38.5%), followed by 12:00 p.m. to 6:00 p.m. (24.0%), 6:00 a.m. to 11:59 a.m. (19.3%), and 12:00 a.m. to 5:59 a.m. (16.4%), 2 D 151:19, p < :001 (see Figure 1). There were significant differences for users age and child age based on the time of question submission. Those users who submitted questions overnight, from 12:00 a.m. to 5:59 a.m., were younger (M D 25:92 years) than those who submitted at other times of the day (M D 26:68 to 27.96), F(3,1258) D 4.21, p D :006. In terms of child age, questions submitted in the evening (mean age D 12.02 months) and overnight .M D 11:98/ were about older children compared to those submitted in the morning .M D 7:17/ and afternoon .M D 11:98/, F(3,1249) D 3.23, p D :022: There were no differences in time of day of submission for mothers compared to fathers, 2 D 3:86, p D :277.
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FIGURE 1 Percent of questions by time of day.
Themes A total of nine themes emerged around parental concerns and questions about young children’s sleep. Themes and representative questions are summarized below and in Table 2. The prevalence of questions for each theme and subtheme are provided in Tables 3 and 4. Night wakings. Night wakings were the most common issue addressed by parents, with 29.53% of total questions coded as this theme. Parental concerns about night wakings were coded into three primary subthemes, including general questions about frequent night wakings (69.47%), issues with feeding back to sleep after a night waking (25.53%), and early morning awakenings (5.53%). General questions about night wakings included such questions as, “He has been waking at night and refusing to go back to sleep. Despite the fact that he is able to put himself to sleep when initially going to bed, he is unable to/refuses to when he wakes at night.” Feeding back to sleep questions focused on the child nursing or being bottle-fed back to sleep during the night. For example, “How can I get my 18-month-old to sleep without a bottle and return to sleep without a bottle?” In addition, parental concerns about night wakings included early morning awakening, in which the child wakes for the day earlier than the parent desires. For example, “All of a sudden my son is waking at 5:00 a.m. when he used to wake at 6:30; how can I change his wake time?” Schedule. The second most common concern related to the young children’s sleep schedules, with 27.89% of total questions coded as this theme. Within the general theme regarding scheduling issues, parental concerns about children’s sleep schedule emphasized naps (50.70%), sleep duration (24.79%), sleep schedule (20.05%), feeding schedule (12.53%), and morning wake time (0.84%). Many parents asked questions about naps, which included the frequency, duration, resistance, or location of intentional daytime sleeping: “How many and how long should naps be during the day?” and “What are good sleep and eat routines? And how
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TABLE 2 Parental Concerns and Questions Regarding Young Children’s Sleep Themes
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1. Night wakings
2. Schedule
3. Bedtime problems 4. Sleep environment
5. Sleep training
6. Parasomnia 7. Health-related sleep issues 8. Sleep-disordered breathing 9. Other sleep issues
Representative Quotes “How can I get her to sleep through the night? She wakes up every 2 hours or so, even if I sleep next to her. I tried the CIO method but then she cries in her sleep and still wakes up from time to time. What should I try next?” “How much sleep does a 2-month-old require? My son seems to want frequent naps during the day. At least 3 to 4 naps, sometimes 1 to 2 hours long. Is this normal?” “My 4-year-old is afraid, wants the light on, wants us to come back in the room, etc. He will yell for us or be really loud so we’ll know he is still awake.” “She will nap in her crib most of the time but at night she loves her swing and won’t either go down in the crib or back in her crib after the middle of the night feeding.” “I would like to know how to put my daughter to bed after her routine that does not involve her crying it out. I am not comfortable doing this and if I put her to bed after her routine she just cries. Admittedly, I have never let her cry for more than 2 or 3 minutes, but by then she is screaming (hands balled into fists, face bright red, and tears)!” “My son often wakes up through the night crying frantically as if he were having a bad dream. Is there anything I can do to stop this from happening?” “How can I help my baby sleep better when she has a cough with phlegm?” “My daughter is 7 months old now, and she breathes really hard when she naps or sleeps throughout the night. Is this normal?” “My daughter wiggles so much at night! Is that normal? We do not wrap her in a blanket like the hospital. Will she ever stop wiggling so much and does this mess with her sleep?”
TABLE 3 Prevalence of Themes Age group
Gender
Theme
Total Sample
Newborn
Infant
Toddler
Older Child
Female
Male
1. 2. 3. 4. 5. 6. 7. 8. 9.
29.53% 27.89% 26.65% 11.42% 9.40% 7.69% 4.51% 0.54% 2.02%
19.96% 27.44% 29.51% 7.99% 4.45% 1.52% 5.41% 0.33% 3.39%
33.51% 18.98% 20.28% 8.86% 10.83% 1.35% 3.97% 0.22% 1.99%
31.35% 15.92% 22.32% 9.97% 10.27% 4.18% 2.15% 3.86% 0.00%
17.63% 4.61% 28.17% 23.45% 4.12% 13.67% 4.39% 0.77% 3.19%
27.12% 21.86% 23.61% 7.45% 11.86% 2.08% 3.24% 1.21% 1.57%
33.12% 18.02% 21.63% 10.97% 6.60% 2.01% 4.88% 0.24% 2.54%
Night wakings Schedule Bedtime problems Sleep environment Sleep training Parasomnias Health-related sleep issues Sleep-disordered breathing Other sleep issues
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Sleep environment
Bedtime problems
Schedule/general sleep
Night wakings
Themes
Bedtime sleep resistance/struggle Adult presence to fall asleep Bedtime routine Bedtime Transition to sleeping independently Feeding to sleep Bedtime fears
Naps Sleep schedule Sleep duration Feeding schedule Morning wake time
1. Transition from co-sleeping to own bed or room 2. General sleep environment 3. Sleep position 4. Pacifier 5. Swaddling 6. Crib safety 7. Cosleeping safety 8. Transition from crib to bed
1. 2. 3. 4. 5. 6. 7.
1. 2. 3. 4. 5.
1. Night wakings 2. Feeding back to sleep 3. Early morning waking
Subthemes
25.85% 20.41% 17.00% 11.56% 11.56% 8.84% 4.76% 2.72%
2.33% 1.94% 1.32% 1.32% 1.01% 0.54% 0.31%
30.61% 22.45% 15.16% 15.45% 11.66% 7.58% 1.75%
50.70% 20.05% 24.79% 12.53% 0.84%
69.47% 25.53% 5.53%
Total Sample % Within Themes
29.53% 20.51% 7.54% 1.63% 27.89% 14.14% 5.60% 5.36% 3.50% 0.23% 26.65% 8.16% 6.00% 4.27% 4.12% 3.10% 2.49% 0.47% 11.42% 2.95%
Total Sample % Overall Sample
TABLE 4 Prevalence of Themes
35.63% 13.65% 10.27% 3.86% 6.04% 16.43% 0.00%
14.13%
22.95% 22.36% 23.45% 9.82% 16.27% 4.87% 0.28%
36.49% 34.73% 12.56% 16.22% 0.00%
64.09% 29.50% 6.41%
Newborn
25.57% 17.25% 8.54% 14.57% 10.67% 6.12% 0.00%
17.27%
35.47% 11.67% 19.65% 9.75% 14.3% 8.59% 0.57%
56.8% 22.32% 7.06% 11.55% 2.27%
63.91% 28.58% 7.50%
Infant
12.02% 1.80% 6.62% 0.00% 0.00% 0.00% 2.93%
76.63%
25.83% 16.03% 9.51% 10.33% 16.26% 15.07% 6.98%
41.16% 33.32% 20.98% 3.68% 0.87%
70.56% 21.4% 8.04%
Toddler
Age Group
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(continued )
3.10% 0.00% 0.00% 0.00% 0.00% 6.65% 5.32%
84.92%
8.42% 22.61% 17.82% 13.53% 21.62% 6.27% 9.74%
22.50% 33.33% 44.17% 0.00% 0.00%
100.00% 0.00% 0.00%
Older Child
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Other sleep issues
Sleep-disordered breathing
Health-related sleep issues
Parasomnias
Sleep training
Themes
Teething Behavioral Health Colic Reflux Coughing/wheezing Vomiting Prematurity
Confusional arousal/sleep terror Nightmare Sleep talking Toilet training Nocturnal enuresis Sleepwalking
1. Restless 2. Family situation 3. Limb Movements
1. 2. 3. 4. 5. 6. 7.
1. 2. 3. 4. 5. 6.
1. Logistics of sleep training 2. Harm to child
Subthemes
2.02% 1.01% 0.54% 0.39%
9.40% 8.86% 0.62% 7.69% 1.70% 0.85% 0.54% 0.39% 0.23% 0.16% 4.51% 1.01% 0.47% 0.39% 0.39% 0.23% 0.23% 0.16% 0.54%
Total Sample % Overall Sample
TABLE 4 (Continued)
50.0% 26.92% 19.23%
—
22.41% 10.34% 8.62% 8.62% 5.17% 5.17% 3.45%
22.22% 11.11% 7.07% 5.05% 3.03% 2.02%
94.21% 6.61%
Total Sample % Within Themes
38.71% 30.72% 30.57%
—
0.00% 14.87% 38.59% 28.46% 0.00% 3.59% 14.49%
0.00% 8.90% 84.32% 3.39% 3.39% 0.00%
100% 0.00%
Newborn
49.36% 5.62% 45.02%
—
64.28% 13.1% 2.93% 4.44% 6.16% 2.58% 6.51%
49.93% 13.24% 27.17% 2.62% 3.72% 3.31%
93.83% 6.17%
Infant
0.00% 0.00% 0.00%
—
29.84% 41.36% 0.00% 0.00% 6.28% 22.51% 0.00%
43.57% 32.44% 2.11% 12.67% 9.21% 0.00%
54.02% 45.98%
Toddler
Age Group
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34.09% 31.82% 34.09%
—
0.00% 89.89% 0.00% 0.00% 0.00% 0.00% 0.00%
26.84% 32.27% 0.00% 17.25% 23.64% 0.00%
100% 0.00%
Older Child
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many hours should babies sleep during the day?” Questions regarding sleep duration involved inquiries about the appropriate length of time a child should sleep, such as, “How many hours all together with night sleep and daytime naps should a 23-month-old be getting? My son sleeps between 9 and 10 hours a night and takes a nap for 2–3 hours during the day. Is this average?” With respect to feeding schedules, parents discussed issues pertaining to the timing of feedings as related to sleep: “Does feeding them a bottle earlier in the bedtime routine cause them to wake earlier for feeding?” Bedtime problems. Parental concerns about bedtime (26.65% of all questions) focused on bedtime struggles/resistance (30.61% within this category), adult presence to fall asleep (22.45%), bedtime routines (15.16%), bedtimes (15.45%), and feeding to sleep (7.58%). These questions addressed issues such as the time of day the child goes to sleep, activities families do prior to bedtime (e.g., taking a bath, reading a story), and child resistance (e.g., fights sleep at bedtime). Furthermore, parents expressed concern regarding needing an adult present to fall asleep and transitioning to sleeping independently. Specifically, when parents asked questions pertaining to adult presence, they stated their child needed to be held, rocked, patted, or an adult needed to be in the room in order for the child to fall asleep: “My 3-month-old will not sleep on her own. What can I do? As soon as I take her out of my arms, she wakes up and cries until picked up.” Parental concerns of transition from cosleeping to sleeping independently were related to how or when to transition a young child: “I am trying to break the habit of cosleeping. My daughter is a big 7-month-old, about the size of babies twice her age, so it’s getting a little crowded. She stands and plays in her crib or screams her head off. What should I do? Will she lie down eventually if I try the cry it out method?” Sleep environment. Approximately 1 out of 10 submitted questions (11.42% of all questions) regarded the sleep environment. The most commonly asked questions within this theme were about the specifics of transitioning the child to sleeping in his/her own crib/bed/room (25.85%; e.g., “My son wakes up a lot at night. Recently I started bringing him to my bed where he sleeps so much better. I’m not completely opposed to cosleeping, but I get up at 5:00 a.m., which means so does he. Any ideas on helping him sleep better all night and in his crib?”). Also asked were questions about the more general sleep environment (20.41%), crib safety (8.84%), cosleeping safety (4.76%), and transitioning from a crib to a bed (2.72%). General questions about the sleep environment included such issues as room temperature and bed clothing, as well as sleep position (e.g., “Is it okay for my baby to sleep on her stomach?”), swaddling, and pacifier questions. In addition, parental concerns regarding crib safety addressed the safety of having items such as bedding or pillows in a crib, as well as climbing out of a crib. Swaddling and pacifier concerns specifically addressed their use or discontinuing: “My son is still swaddled at night and today he rolled over for the first time. How do I get him to sleep without swaddling?” Sleep training. Parental concerns regarding sleep training (9.40% of all questions) emphasized the logistics of sleep training (94.21%) and the possibility that sleep training would harm their child (6.61%). Questions were included in this category if the parent directly utilized the phrase “sleep training,” if they asked in more general terms about helping babies learn to
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fall asleep on their own, or if they referred to “crying it out.” Very few questions related to parental worry about using crying it out methods: “Should I be concerned about increased cortisol levels for such a young infant? At what level of intensity or duration of crying would you start to become concerned about stress hormones?” Instead, most questions were more general about the logistics of implementing sleep training: “We are doing CIO with checks every 15 minutes. Is it okay to give her the pacifier during the checks? It works so well to calm her down and get her back to sleep.” Parasomnias. For these questions (7.69% of all questions), parents addressed various types of parasomnias, including nightmares (11.11%), sleepwalking (2.02%), sleep talking (7.07%), confusional arousals/sleep terrors (22.22%), nocturnal enuresis (3.03%), and toilet training (5.05%). In regard to confusional arousals/sleep terrors, parental concerns were related to young children screaming, crying, or whining, and not being completely awake (e.g., “My son often wakes up through the night crying frantically as if he was having a bad dream. Is there anything I can do to stop this from happening?”). Additionally, questions about confusional arousals included seeming disoriented while sleeping overnight or during naps. Toilet training issues were related to wearing a diaper or pull-up at night or how to manage toilet training through the night. Health-related sleep issues. This theme included health issues that were related to sleep concerns (4.51% of all questions). Parents were primarily concerned about sleep issues related to teething (22.41%), as well as reflux (8.62%), colic (8.62%), coughing/wheezing (5.17%), vomiting (5.17%), prematurity (3.45%), and behavioral health (10.34%; e.g., sleep issues related to child ADHD, depression, or anxiety). For example, “My daughter’s family has moved into a new home and they have a new baby due soon. The big sister has gone from sleeping all night to waking several times a night. We’re sure it’s anxiety from all the new things, but any suggestions?” Sleep-disordered breathing. Concerns about sleep-disordered breathing (0.54% of all questions) were mentioned infrequently. These parental concerns were related to snoring, noisy breathing, or pauses in breathing: “My baby wakes up when I put her down to her bassinet no matter how long I hold her. Her breathing also sounds like she has mucus in her throat. She just started this week and she makes noises while asleep too.” Other sleep issues. Finally, a few questions addressed other sleep issues (2.02%), which were not captured within the previously discussed themes. These few questions and concerns emphasized restlessness (50.00%), limb movements (19.23%), or family situations (26.92%). When parents mentioned limb movements, it was usually related to sudden arm or leg movements during sleep: “Ross thrashes around a lot when he sleeps. This causes him to wake and scream. This in turn will keep him up for up to 2 hours at a time. How should I control his rolling and make his crib safer to sleep in?” Concerns about family situations often focused on the presence of a sibling in the family or bedroom: “I have twin baby boys. I have been having a hard time getting them down without rocking them to sleep. I try to put them down but they seem to wake each other up. Any tips on how to deal with twin sleeping?”
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Gender and Age Differences in Themes Differences in prevalence of themes based on child gender and age are presented in Table 3. Overall, there were minimal differences in themes for boys compared to girls, although twice as many questions regarding sleep training in girls came in as for boys. As expected, differences were found across age groups. In looking at the general themes, questions regarding newborns were primarily about bedtime problems (29.51%) and newborns’ sleep schedules (27.44%), with night wakings also a common concern (19.96%). In contrast, questions submitted by parents of infants and toddlers were most concerned about night wakings (33.51% and 31.35%, respectively). In older children, bedtime problems (28.17%) and the sleep environment (23.45%), primarily transitioning to sleeping in own room or to a bed, were the focus. Night wakings, however, continued to be an issue for some parents (17.63%). In order to enumerate the differences among age groups, the prevalence of subthemes was explored (see Table 4). Across all age groups, questions about night wakings were primarily focused on general night waking concerns, such as the frequency and duration of night wakings. Feeding back to sleep was a consistent concern from birth to three years, but not a concern in older children. Within the category of sleep schedule, parents of newborns were equally concerned about naps and general sleep schedule, whereas parents of both infants and toddlers primarily asked about naps, with general sleep schedule concerns second in likelihood. Parents of older children who asked questions about schedule/general sleep focused on sleep duration. In the area of bedtime problems, questions were fairly consistent across the ages, with parents of newborns focused on adult presence to fall asleep, bedtime routine, and bedtime sleep resistance/struggle, whereas parents of infants and toddlers emphasized bedtime sleep resistance/struggle. In addition, parents of older children focused on adult presence to fall asleep, transition to sleeping independently, and bedtime routines. Questions regarding sleep environment shifted from few parents of newborns asking about transitioning from cosleeping to independent sleeping to almost all questions appearing in this category for parents of toddlers and older children. As expected, sleep position and swaddling were no longer a concern after infancy, nor were general crib safety and cosleeping safety. Finally, within health-related sleep issues, parents of newborns focused on colic and reflux, while parents of infants emphasized teething. Parents of toddlers and older children who asked questions about health-related sleep issues emphasized behavioral health.
Parent Differences in Themes Differences in prevalence of themes based on mothers compared to fathers are presented in Figure 2. Overall, mothers asked more questions about night wakings, bedtime problems, and schedules than other topics. Similarly, fathers asked more questions about night wakings and bedtime problems than other topics. Although the proportions of questions asked by mothers and fathers were quite similar in that the majority of questions asked were about night wakings, bedtime problems, and schedules, mothers asked somewhat more questions (proportionally) about schedules and sleep training than did fathers. Almost no fathers asked about sleep training (1.44%) compared to mothers (9.37%).
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FIGURE 2
Theme by user.
Word Prevalence A word cloud created from the text of the original submissions is presented in Figure 3. It provides a representation of the most common words appearing across all submitted questions. The size of the word represents how frequently it was used. As expected, the word sleep appears the most often. The next two most frequently occurring words are night and wakes, which is consistent with the dominant theme of night wakings.
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FIGURE 3
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Word cloud representation of most frequently occurring words.
FIGURE 4
Pronoun use in questions submitted.
Finally, pronoun choice by user was established, in regard to their use of “I” versus “he/she/son/daughter.” The results are represented in the Venn diagram in Figure 4. As expected, of those questions that included any of these pronouns, the majority included both in their questions (n D 507; 56.6%). If the question only included one of these terms, respondents were almost twice as likely to use the term “he/she/son/daughter” only (n D 262; 29.2%) as to use “I” only (n D 127; 14.2%). There were no differences in fathers’ and mothers’ choice of pronouns, 2 D :98, p D :61.
DISCUSSION This study found that parents/caregivers are most concerned about bedtime problems, night wakings, and sleep schedule issues with their infants and toddlers, accounting for almost 85%
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of all questions submitted. More specifically, about the problem of night wakings in general was the number one most common concern of parents, accounting for 21% of all questions, followed by questions about naps (14%). Issues associated with feeding back to sleep during the night and bedtime resistance/struggles each comprised 8% of all submissions. The rest of all submissions covered a broad array of topics, from questions about swaddling to bedwetting. Overall, there were no differences in questions asked based on the gender of the child. This finding is consistent with past research that has found limited, if any, gender differences in sleep in young children (Mindell, Meltzer, Carskadon, & Chervin, 2009; Sadeh et al., 2009). Not surprisingly, however, the types of concerns changed across this developmental period, with parents of newborns equally concerned about their child’s night wakings, bedtime issues, and general sleep schedule. In contrast, parents of infants and toddlers were most likely to ask questions about night wakings, which comprised one third of all questions submitted. Finally, parents of older children were most concerned about transitioning from a crib to a bed and having their child transition to sleeping independently. Not surprisingly, parents of newborns and infants had concerns about such issues as their child’s sleep position, swaddling, and pacifiers, but these types of questions were not asked by parents of toddlers or older children. This differential lends support to the validity of these data regarding the concerns that parents have at different developmental stages. Interestingly, there were few questions about more medically based sleep issues, especially sleep-disordered breathing. Only 0.5% of questions submitted were related to such issues as snoring or noisy breathing, although one study indicated that approximately 9% of infants experience habitual snoring (Piteo et al., 2011), and a second study found prevalence rates of “always” snoring ranging from 3.6% at 1.5 years to a peak of 7.7% at 3.5 years, and habitual snoring of 9.6% at 1.5 years to 21% at 3.5 years (Bonuck et al., 2011). This result supports the need for increased education of parents about a broad array of sleep issues, especially to increase awareness of symptoms of sleep-disordered breathing. These results also provide practitioners and researchers with an understanding of what concerns are most common in parents in real-world settings, rather than what is known from studies that use forced-choice questions and limited lists of concerns that parents can endorse. More in-depth analyses enabled assessment of nuances in parental concerns. For example, we found that although the primary concerns of mothers and fathers were similar, mothers are more likely to ask questions about sleep training especially, as well as sleep schedules. This differential may reflect differences in parental roles, with mothers possibly more likely to be involved in sleep training and family schedules, or more concerned about making changes. Previous studies have found differences in paternal and maternal cognitions about sleep in young children (Sadeh, Flint-Ofir, Tirosh, & Tikotzky, 2007), which may be further reflected in our findings. In addition, the analysis of pronoun use in questions submitted seems to indicate that parents are more likely to attribute the sleep-related problem (and potentially the solution) to the child rather than anticipating the need to change their own behavior in order to rectify the sleep-related problem. These findings are similarly supported by research on parental cognitions about sleep, with previous research indicating that maternal cognitions related to concerns about infants’ distress at night are associated with more disturbed sleep, while maternal cognitions emphasizing the importance of limit-setting are associated with more consolidated sleep (Morrell, 1999; Sadeh et al., 2007; Tikotzky & Sadeh, 2009). The use of “I” may reflect increased beliefs about internal control regarding their child’s sleep, whereas the
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use of “he/she/son/daughter” may indicate cognitions that attribute sleep issues as controlled more by the child. Future research is needed to further explore these subtle nuances in language and whether they are indicative of cognitions that impact sleep and sleep issues. Although not a primary aim of this study, it was interesting to note that almost half of all questions submitted by users occurred between 6:00 p.m. and 6:00 a.m., when primary care providers are not typically accessible. Parents may have submitted their questions during this period because it was when they may have been more likely to be utilizing technology or it may be when questions about sleep are most likely to arise. The high utilization of this service, especially during off-peak hours, supports parental interest in accessible information and advice throughout the day and night (Siemer, Fogel, & Van Voorhees, 2011). The primary limitation of this study was that the sample is likely quite homogenous, as it only included parents who were iPhone/iPad users and those who sought out an app related to sleep in young children. However, studies show that 81% of U.S. adults aged 25–34 (the primary study demographic) own a smartphone. Furthermore, while smartphone ownership increases with income and education, the effect of income is small; for people with incomes below $30,000, smartphone ownership is 77% as compared to 90% for incomes over $75,000. Note, though, that iPhone ownership does tend to skew more sharply toward high income and more education than the Android platform (Smith, 2013). In addition, the parents submitting questions represented a diverse age group and the sample studied represents the parents who will most likely utilize telemedicine resources. Further, this app and service were publicly available and thus free to be utilized by parents of any socioeconomic status as long as they had access to an iPhone or iPad. Finally, a unique aspect of this study is that this is nonclinical real world data (RWD) regarding parental concerns. Overall, this study found that parents are most concerned about night wakings in young children, as well as bedtime problems and sleep schedules. Knowledge of the primary concerns of parents can help guide health care practitioners in the presentation of the most applicable prevention and education efforts in their interactions of families and with broader education initiatives. Furthermore, a need continues for the development and availability of telemedicine resources for parents, including Internet-based resources, as well as app-based and other technologically available resources.
ACKNOWLEDGMENTS This study was sponsored by Johnson & Johnson Consumer Consumer Companies, Inc. Dr. Mindell has served as a consultant and speaker for Johnson & Johnson. Dr. Leichman and Mr. Bhullar have served as consultants for Johnson & Johnson. Dr. Walters is an employee of Johnson & Johnson.
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