Indian J Pediatr DOI 10.1007/s12098-015-1728-0
ORIGINAL ARTICLE
Sleep Habits and Sleep Problems in Healthy Preschoolers C L Srinivasa Murthy & Bhavneet Bharti & Prahbhjot Malhi & Alka Khadwal
Received: 8 August 2014 / Accepted: 12 February 2015 # Dr. K C Chaudhuri Foundation 2015
Abstract Objectives To describe the sleep patterns and problems in children aged between 12 and 36 mo of age. Methods This cross sectional survey was collected over a span of 1 y in Advanced Pediatric Centre, PGIMER, Chandigarh and crèches of Chandigarh. Children in the age group of 12 to 36 mo were included in study. Children with chronic illness, developmental delay, seizure disorder and lack of consent were excluded. A total of 368 children were enrolled. Main outcome measures were sleep duration over 1 to 3 y of life; sleep behavior at onset, during and waking of sleep and parent reported sleep problems and their predictors. Results The average duration of sleep was 12.5 h (S.D= 1.9). The mean total sleep duration and mean day time sleep duration decreased, while mean night time sleep increased as the age advanced from 12 to 36 mo. Following were the frequency of sleep habits seen in the index study; bed time routine was seen only in 68(18.5 %), a regular bed time ritual was seen in 281(76.4 %), 329(89.4 %) children frequently required 0–20 min time to fall asleep, 11(3 %) parents used sleep inducing drugs. Night waking (1 to 3 times a night) was seen in 297(80.7 %) and its frequency declined with age. Parent reported sleep problems were seen in 12.8 % (47/368). Lack of co-sleeping and night waking were considered as strongest predictors of parent reported sleep problems. Conclusions Toddlers’ sleep duration, night waking behavior, and day time naps decrease as the age progress while night time sleep duration increases with age. Lack of co-sleeping C. L. S. Murthy Department of Pediatrics, Basaveshwara Medical College and Hospital, Chitradurga, Karnataka, India B. Bharti (*) : P. Malhi : A. Khadwal Department of Pediatrics, Advanced Pediatric Centre, Postgraduate Institute of Medical Education & Research, Chandigarh 160012, India e-mail: [email protected]
and night waking are considered as strongest predictors of parent reported sleep problems. Keywords Sleep in children . Sleep pattern . Sleep habits . Toddlers sleep . Sleep problems . Predictors of sleep problem . Co-sleeping in children . Sleep duration
Introduction Sleep plays an important role in the physical growth, behavior and emotional development of children and is closely related to cognitive functioning, learning and attention [1, 2]. The first 3 y of life are vital for the acquisition and stabilization of various physiological functions, including the sleep-wake cycle. Sleep architecture and sleep behaviors change drastically across the age spectrum from infancy to adolescence. Therefore, it is not easy to define normal sleep behavior and what falls outside a picture of normality. Identifying these behavioral problems is important in order to define an effective treatment of these conditions [3, 4]. Moreover, sleep patterns and problems vary across cultures and there is paucity of data from India on the prevalence of sleep problems especially in toddlers [5, 6]. In view of the above considerations, this study was conducted to gather indicative data on sleep behavior and problems in children aged 12 to 36 mo.
Material and Methods The study was conducted for a duration of 14 mo, of which 2 mo were dedicated for data analysis. Data was collected from the following sources: Outpatient department (OPD) of Advanced Pediatric Centre, Post Graduate Institute of Medical Education and Research (Healthy children who come for
Indian J Pediatr
routine follow up, children with minimal illness and accompanying sibs if any) and from the Crèches of Chandigarh. The questionnaire was administered by the investigator while the parents were waiting outside the OPD in Advanced Pediatric Centre or in Crèches when the parents came to leave or take their children. The sleep behavior was measured using the standardized questionnaire authored by Elisa Fazzi [7]. This questionnaire was modified for Indian children and then applied. Written permission from the author of the questionnaire was taken. The questionnaire covered two broad areas of investigation (clinical history and sleep characteristics). A consent form describing the study and requesting participation accompanied each questionnaire. Children were enrolled into the study only after the parents signed the consent from. The questionnaire was both in English and Hindi. The questionnaire was made up of different parts and was structured in a series of single answers, Multiple Choice Questions and Forced Choice Questions (Yes/No). The final unstructured part allowed the parents to express their opinion freely. Demographic and housing information were also collected. Several questions addressing the issue of children’s sleep were asked. Children with chronic illness, developmental delay, seizure disorder and those who refused to consent were excluded from the study. The medical histories of the children were explored and specific questions were asked to identify the exclusions. In case the parents had eligible sibs accompanying the children to the hospital or crèches, they were also enroled in the study. The investigator was always there to help or clarify any doubts of parents about the filling of the questionnaire. Approximate time for filling the proforma was between 40 and 60 min. If parents were not sure of certain answers, they were instructed to keep sleep log for 1– 2 wk and they were contacted later to fill the missing information. Sample size was calculated before the study was begun. Total number of children required was calculated according to the formula=Z2 p (1-p)/d2, where p is the proportion of children having sleep problem, which according to the literature search is around 25–40 % (0.25–0.40); d is the desired margin of error. Z is the critical value for alpha, for 0.05 alpha, Z is 1.96. So the sample size was=(1.96)2 × 0.4(0.6)/ (0.05)2 =368 children. The preliminary analysis of the data was based on calculation of the frequency of the parents’ response to the items contained in the sleep behavior questionnaire, and of the percentage distribution and mean values of these responses. One way ANOVA was used to detect the association of various demographic and sleep variables. Multivariate analysis was used to detect the independent predictors of parent reported sleep problem.
Results A total of 539 sleep questionnaires were distributed to the parents. One hundred seventy one children were excluded from the study. Among these 171 children, 126 were from
crèches and 45 were from outpatient clinic. Parents of 153 subjects (118 from crèches and 35 from outpatient clinic) did not return proforma inspite of repeated requests, 7 children had developmental delay, 3 had epilepsy and 8 had chronic disease (2 had atopic dermatitis, 2 had chronic diarrhea, 1 had nephrotic syndrome, 1 had tuberculosis on treatment, 1 had recurrent wheeze, 1 had celiac disease). The study entailed a total of 368 subjects who were evaluated by using sleep questionnaire. Among this, 338 children were enrolled from outpatient clinic and 30 children were enrolled from crèches. Some important demographic characteristics of the study cohort are shown in the Table 1. Environmental factors such as presence of noise and exposure to second hand smoke in sleep environment were seen in 50 (13.6 %) and 33 (9 %) children respectively. Data on the presence or absence of television in bed room were not available. Total mean sleep duration was 12.5 h (S.D=1.9) in the study cohort. The mean total sleep duration decreased gradually as the age advanced from 12 to 36 mo. Highest total sleep duration was observed in children aged 30 mo with a mean sleep duration of 11.97(SD 2.27)h. Overall, one way ANOVA showed statistically highly significant difference for total sleep duration among 4 age group children (F value 9.08; p 0.0001). Day time sleep duration also followed similar trend with highest day time mean sleep duration of 3.41 (SD 1.20)h observed in children age 30 mo Gender Male Female Area Urban Rural Put to bed by the same person No Yes Put the bed at regular time No Yes Bed time ritual No Yes Night waking ≤3 awakening >3 awakening Length of awakening ≤30 min >30 min Co-sleeping Present Absent *p3 times was strongest with O.R of 15.06 % (95 % C I: 6.70–33.88) (p 0.0001) followed by lack of co-sleeping. The odds of sleep problem were increased by almost 3 times in children who were not cosleeping in the index study (O.R 2.98; CI: 1.29–6.89) (p 0.01). Mother’s education was also a weak independent predictor of sleep problem in children, with slightly increased trend of sleep problem with increasing education of mothers (O.R 1.38; 95 % CI: 0.95–1.98) (p 0.08). Similarly there were marginally higher odds of sleep problem if same caretaker was putting the child to sleep (OR 2.37; 95 % CI 0.88–6.37) (p 0.09). Overall diagnostic accuracy of these 4 predictors was 89.3 % and it explained 26.5 % of total variability in the outcome of sleep problem.
Discussion Sleep needs declines considerably from the newborn period to late adolescence, but substantial variability exists in all age groups. Mean total sleep duration in the index study cohort mirrors the findings of others studies in majority of aspects [8, 9]. In a large longitudinal study, Iglowstein et al. found a mean total sleep duration in 1-y-old infants of 13.9 h and at 3 y 12.5 h which is similar to the index 1-y-olds but almost an hour less at 3 y of age. Contribution of daytime sleep to total sleep duration is higher in the present 1-y-olds as compared to Zurich longitudinal study [9]. However in an another recent web based study of more than 5000 children by Sadeh et al. [10] the total duration of sleep, night sleep and daytime sleep was almost in agreement with the present results. As expected, daytime napping frequency also decreased with advancing age. Similar to the trends reported by the Zurich longitudinal study [9, 11], the frequency of napping once per day at 3 y was around 50 % in the present study cohort. The napping frequency decreased as the age progressed in the index study. This age related differences for nap measures are consistent with the results of Weissbluth’s longitudinal data for napping over the preschool-age years [12]. Sleeping supine was seen in 41 % of US children as compared to the index study where sleeping Table 5
Multivariate odds ratio for the outcome of sleep problem
Predictor
Multivariate odds ratio 95 % C.I
P value
Mothers education Same person to sleep Night waking > 3 times Absent co-sleeping
1.38 2.37 15.06 2.98
0.08 0.09 3) were found to be important reasons for parents to subjectively view their child’s sleep as a problem and this is similar to many other studies. Most of the parental characteristics (e.g., socio-economic status, education, and age) did not have a significant contribution in predicting parental perception. Except that there was slightly increased incidence of sleep problems in mothers who were better educated (Graduates), well educated mothers reported sleep problems more frequently. This may be because that they are better reporters or the multiplicity of the duties of mother both at home or outside could have made this labor intensive aspect of mothering subjectively as problematic. This study has many limitations; first and foremost is selection bias which may have affected this sample of
Indian J Pediatr
convenience. Most of the children were recruited from the outdoor department of an academic institute which may not generalize to a more heterogeneous population based community sample. The other limitation of this study is the use of parental report and the lack of verification of the parental reports by more objective data. In conclusion, the total duration of sleep, day time sleep duration and number of naps during day time showed age related difference and declined as the age of the child increased. When compared to other studies, the present population reported lesser parent reported sleep problems but the incidence of co-sleeping and night waking were high. And lastly, the major independent predictors for parent reported sleep problems in the index study population were frequent night waking and lack of co-sleeping. Further studies are required on a larger sample size to confirm and generalize the results that have been obtained. Contributions SMCL: Data collection and analysis; BB: Study protocol and data analysis; PM: Data collection; AK: Final correction and data collection. BB will act as guarantor for this paper. Conflict of Interest None. Source of Funding None.
References 1. Oswald I. Sleep as restorative process: human clues. Prog Brain Res. 1980;53:279–88. 2. Anders TF, Eiben LA. Pediatric sleep disorders: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry. 1997;36:9–20. 3. Morgenthaler TI, Owens J, Alessi C, et al. Practice parameters for behavioral treatment of bedtime problems and night wakings in infants and young children. Sleep. 2006;29:1277–81. 4. Mindell JA, Du Mond CE, Sadeh A, Telofski LS, Kulkarni N, Gunn E. Efficacy of an internet-based intervention for infant and toddler sleep disturbances. Sleep. 2011;34:451–8. 5. Mindell JA, Sadeh A, Wiegand B, How TH, Goh DY. Cross-cultural differences in infant and toddler sleep. Sleep Med. 2010;11:274–80. 6. Kohyama J, Mindell JA, Sadeh A. Sleep characteristics of young children in Japan: internet study and comparison with other Asian countries. Pediatr Int. 2011;53:649–55. 7. Fazzi E, Zaccagnino M, Capsoni C, et al. A questionnaire on sleep behaviour in the first years of life: preliminary results from a normative sample. Funct Neurol. 2006;21:151–8.
8. Iglowstein I, Jenni OG, Molinari L, Largo RH. Sleep duration from infancy to adolescence: reference values and generational trends. Pediatrics. 2003;111:302–7. 9. Bamford FN, Bannister RP, Benjamin CM, Hillier VF, Ward BS, Moore WM. Sleep in the first year of life. Dev Med Child Neurol. 1990;32:718–24. 10. Sadeh A, Mindell JA, Luedtke K, Wiegand B. Sleep and sleep ecology in the first 3 years: a web-based study. J Sleep Res. 2009;18:60– 73. 11. Ward TM, Gay C, Anders TF, Alkon A, Lee KA. Sleep and napping patterns in 3-to-5-year old children attending full-day childcare centers. J Pediatr Psychol. 2008;33:666–72. 12. Weissbluth M. Naps in children: 6 months-7 years. Sleep. 1995;18: 82–7. 13. Latz S, Wolf AW, Lozoff B. Cosleeping in context: sleep practices and problems in young children in Japan and the United States. Arch Pediatr Adolesc Med. 1999;153:339–46. 14. Yang CK, Hahn HM. Cosleeping in young Korean children. J Dev Behav Pediatr. 2002;23:151–7. 15. Mindell JA, Sadeh A, Kohyama J, How TH. Parental behaviors and sleep outcomes in infants and toddlers: a cross-cultural comparison. Sleep Med. 2010;11:393–9. 16. Adair R, Bauchner H, Philipp B, Levenson S, Zuckerman B. Night waking during infancy: role of parental presence at bedtime. Pediatrics. 1991;87:500–4. 17. Scott G, Richards MP. Night waking in 1-year-old children in England. Child Care Health Dev. 1990;16:283–302. 18. Anders TF, Halpern LF, Hua J. Sleeping through the night: a developmental perspective. Pediatrics. 1992;90:554–60. 19. Gaylor EE, Goodlin-Jones BL, Anders TF. Classification of young children’s sleep problems: a pilot study. J Am Acad Child Adolesc Psychiatry. 2001;40:61–7. 20. Ottaviano S, Giannotti F, Cortesi F, Bruni O, Ottaviano C. Sleep characteristics in healthy children from birth to 6 years of age in the urban area of Rome. Sleep. 1996;19:1–3. 21. Morrell JM. The role of maternal cognitions in infant sleep problems as assessed by a new instrument, the maternal cognitions about infant sleep questionnaire. J Child Psychol Psychiatry. 1999;40:247–58. 22. Goodlin-Jones BL, Burnham MM, Gaylor EE, Anders TF. Night waking, sleep-wake organization, and self-soothing in the first year of life. J Dev Behav Pediatr. 2001;22:226–33. 23. Bharti B, Mehta A, Malhi P. Sleep problems in children: a guide for primary care physicians. Indian J Pediatr. 2013;80:492–8. 24. Bharti B, Malhi P, Kashyap S. Patterns and problems of sleep in school going children. Indian Pediatr. 2006;43:35–8. 25. Jenni OG, O’Connor BB. Children’s sleep: an interplay between culture and biology. Pediatrics. 2005;115:S204–16. 26. Baldi I, Gulati A, Lorenzoni G, et al. Public health implications of obstructive sleep apnea burden. Indian J Pediatr. 2014;81:S55–62. 27. Ravikiran SR, Kumar PM, Latha KS. Sleep problems in preschool and school aged rural Indian children. Indian Pediatr. 2011;48:221–3. 28. Bayer JK, Hiscock H, Hampton A, Wake M. Sleep problems in young infants and maternal mental and physical health. J Paediatr Child Health. 2007;43:66–73.
ORIGINAL ARTICLE
Sleep Habits and Sleep Problems in Healthy Preschoolers C L Srinivasa Murthy & Bhavneet Bharti & Prahbhjot Malhi & Alka Khadwal
Received: 8 August 2014 / Accepted: 12 February 2015 # Dr. K C Chaudhuri Foundation 2015
Abstract Objectives To describe the sleep patterns and problems in children aged between 12 and 36 mo of age. Methods This cross sectional survey was collected over a span of 1 y in Advanced Pediatric Centre, PGIMER, Chandigarh and crèches of Chandigarh. Children in the age group of 12 to 36 mo were included in study. Children with chronic illness, developmental delay, seizure disorder and lack of consent were excluded. A total of 368 children were enrolled. Main outcome measures were sleep duration over 1 to 3 y of life; sleep behavior at onset, during and waking of sleep and parent reported sleep problems and their predictors. Results The average duration of sleep was 12.5 h (S.D= 1.9). The mean total sleep duration and mean day time sleep duration decreased, while mean night time sleep increased as the age advanced from 12 to 36 mo. Following were the frequency of sleep habits seen in the index study; bed time routine was seen only in 68(18.5 %), a regular bed time ritual was seen in 281(76.4 %), 329(89.4 %) children frequently required 0–20 min time to fall asleep, 11(3 %) parents used sleep inducing drugs. Night waking (1 to 3 times a night) was seen in 297(80.7 %) and its frequency declined with age. Parent reported sleep problems were seen in 12.8 % (47/368). Lack of co-sleeping and night waking were considered as strongest predictors of parent reported sleep problems. Conclusions Toddlers’ sleep duration, night waking behavior, and day time naps decrease as the age progress while night time sleep duration increases with age. Lack of co-sleeping C. L. S. Murthy Department of Pediatrics, Basaveshwara Medical College and Hospital, Chitradurga, Karnataka, India B. Bharti (*) : P. Malhi : A. Khadwal Department of Pediatrics, Advanced Pediatric Centre, Postgraduate Institute of Medical Education & Research, Chandigarh 160012, India e-mail: [email protected]
and night waking are considered as strongest predictors of parent reported sleep problems. Keywords Sleep in children . Sleep pattern . Sleep habits . Toddlers sleep . Sleep problems . Predictors of sleep problem . Co-sleeping in children . Sleep duration
Introduction Sleep plays an important role in the physical growth, behavior and emotional development of children and is closely related to cognitive functioning, learning and attention [1, 2]. The first 3 y of life are vital for the acquisition and stabilization of various physiological functions, including the sleep-wake cycle. Sleep architecture and sleep behaviors change drastically across the age spectrum from infancy to adolescence. Therefore, it is not easy to define normal sleep behavior and what falls outside a picture of normality. Identifying these behavioral problems is important in order to define an effective treatment of these conditions [3, 4]. Moreover, sleep patterns and problems vary across cultures and there is paucity of data from India on the prevalence of sleep problems especially in toddlers [5, 6]. In view of the above considerations, this study was conducted to gather indicative data on sleep behavior and problems in children aged 12 to 36 mo.
Material and Methods The study was conducted for a duration of 14 mo, of which 2 mo were dedicated for data analysis. Data was collected from the following sources: Outpatient department (OPD) of Advanced Pediatric Centre, Post Graduate Institute of Medical Education and Research (Healthy children who come for
Indian J Pediatr
routine follow up, children with minimal illness and accompanying sibs if any) and from the Crèches of Chandigarh. The questionnaire was administered by the investigator while the parents were waiting outside the OPD in Advanced Pediatric Centre or in Crèches when the parents came to leave or take their children. The sleep behavior was measured using the standardized questionnaire authored by Elisa Fazzi [7]. This questionnaire was modified for Indian children and then applied. Written permission from the author of the questionnaire was taken. The questionnaire covered two broad areas of investigation (clinical history and sleep characteristics). A consent form describing the study and requesting participation accompanied each questionnaire. Children were enrolled into the study only after the parents signed the consent from. The questionnaire was both in English and Hindi. The questionnaire was made up of different parts and was structured in a series of single answers, Multiple Choice Questions and Forced Choice Questions (Yes/No). The final unstructured part allowed the parents to express their opinion freely. Demographic and housing information were also collected. Several questions addressing the issue of children’s sleep were asked. Children with chronic illness, developmental delay, seizure disorder and those who refused to consent were excluded from the study. The medical histories of the children were explored and specific questions were asked to identify the exclusions. In case the parents had eligible sibs accompanying the children to the hospital or crèches, they were also enroled in the study. The investigator was always there to help or clarify any doubts of parents about the filling of the questionnaire. Approximate time for filling the proforma was between 40 and 60 min. If parents were not sure of certain answers, they were instructed to keep sleep log for 1– 2 wk and they were contacted later to fill the missing information. Sample size was calculated before the study was begun. Total number of children required was calculated according to the formula=Z2 p (1-p)/d2, where p is the proportion of children having sleep problem, which according to the literature search is around 25–40 % (0.25–0.40); d is the desired margin of error. Z is the critical value for alpha, for 0.05 alpha, Z is 1.96. So the sample size was=(1.96)2 × 0.4(0.6)/ (0.05)2 =368 children. The preliminary analysis of the data was based on calculation of the frequency of the parents’ response to the items contained in the sleep behavior questionnaire, and of the percentage distribution and mean values of these responses. One way ANOVA was used to detect the association of various demographic and sleep variables. Multivariate analysis was used to detect the independent predictors of parent reported sleep problem.
Results A total of 539 sleep questionnaires were distributed to the parents. One hundred seventy one children were excluded from the study. Among these 171 children, 126 were from
crèches and 45 were from outpatient clinic. Parents of 153 subjects (118 from crèches and 35 from outpatient clinic) did not return proforma inspite of repeated requests, 7 children had developmental delay, 3 had epilepsy and 8 had chronic disease (2 had atopic dermatitis, 2 had chronic diarrhea, 1 had nephrotic syndrome, 1 had tuberculosis on treatment, 1 had recurrent wheeze, 1 had celiac disease). The study entailed a total of 368 subjects who were evaluated by using sleep questionnaire. Among this, 338 children were enrolled from outpatient clinic and 30 children were enrolled from crèches. Some important demographic characteristics of the study cohort are shown in the Table 1. Environmental factors such as presence of noise and exposure to second hand smoke in sleep environment were seen in 50 (13.6 %) and 33 (9 %) children respectively. Data on the presence or absence of television in bed room were not available. Total mean sleep duration was 12.5 h (S.D=1.9) in the study cohort. The mean total sleep duration decreased gradually as the age advanced from 12 to 36 mo. Highest total sleep duration was observed in children aged 30 mo with a mean sleep duration of 11.97(SD 2.27)h. Overall, one way ANOVA showed statistically highly significant difference for total sleep duration among 4 age group children (F value 9.08; p 0.0001). Day time sleep duration also followed similar trend with highest day time mean sleep duration of 3.41 (SD 1.20)h observed in children age 30 mo Gender Male Female Area Urban Rural Put to bed by the same person No Yes Put the bed at regular time No Yes Bed time ritual No Yes Night waking ≤3 awakening >3 awakening Length of awakening ≤30 min >30 min Co-sleeping Present Absent *p3 times was strongest with O.R of 15.06 % (95 % C I: 6.70–33.88) (p 0.0001) followed by lack of co-sleeping. The odds of sleep problem were increased by almost 3 times in children who were not cosleeping in the index study (O.R 2.98; CI: 1.29–6.89) (p 0.01). Mother’s education was also a weak independent predictor of sleep problem in children, with slightly increased trend of sleep problem with increasing education of mothers (O.R 1.38; 95 % CI: 0.95–1.98) (p 0.08). Similarly there were marginally higher odds of sleep problem if same caretaker was putting the child to sleep (OR 2.37; 95 % CI 0.88–6.37) (p 0.09). Overall diagnostic accuracy of these 4 predictors was 89.3 % and it explained 26.5 % of total variability in the outcome of sleep problem.
Discussion Sleep needs declines considerably from the newborn period to late adolescence, but substantial variability exists in all age groups. Mean total sleep duration in the index study cohort mirrors the findings of others studies in majority of aspects [8, 9]. In a large longitudinal study, Iglowstein et al. found a mean total sleep duration in 1-y-old infants of 13.9 h and at 3 y 12.5 h which is similar to the index 1-y-olds but almost an hour less at 3 y of age. Contribution of daytime sleep to total sleep duration is higher in the present 1-y-olds as compared to Zurich longitudinal study [9]. However in an another recent web based study of more than 5000 children by Sadeh et al. [10] the total duration of sleep, night sleep and daytime sleep was almost in agreement with the present results. As expected, daytime napping frequency also decreased with advancing age. Similar to the trends reported by the Zurich longitudinal study [9, 11], the frequency of napping once per day at 3 y was around 50 % in the present study cohort. The napping frequency decreased as the age progressed in the index study. This age related differences for nap measures are consistent with the results of Weissbluth’s longitudinal data for napping over the preschool-age years [12]. Sleeping supine was seen in 41 % of US children as compared to the index study where sleeping Table 5
Multivariate odds ratio for the outcome of sleep problem
Predictor
Multivariate odds ratio 95 % C.I
P value
Mothers education Same person to sleep Night waking > 3 times Absent co-sleeping
1.38 2.37 15.06 2.98
0.08 0.09 3) were found to be important reasons for parents to subjectively view their child’s sleep as a problem and this is similar to many other studies. Most of the parental characteristics (e.g., socio-economic status, education, and age) did not have a significant contribution in predicting parental perception. Except that there was slightly increased incidence of sleep problems in mothers who were better educated (Graduates), well educated mothers reported sleep problems more frequently. This may be because that they are better reporters or the multiplicity of the duties of mother both at home or outside could have made this labor intensive aspect of mothering subjectively as problematic. This study has many limitations; first and foremost is selection bias which may have affected this sample of
Indian J Pediatr
convenience. Most of the children were recruited from the outdoor department of an academic institute which may not generalize to a more heterogeneous population based community sample. The other limitation of this study is the use of parental report and the lack of verification of the parental reports by more objective data. In conclusion, the total duration of sleep, day time sleep duration and number of naps during day time showed age related difference and declined as the age of the child increased. When compared to other studies, the present population reported lesser parent reported sleep problems but the incidence of co-sleeping and night waking were high. And lastly, the major independent predictors for parent reported sleep problems in the index study population were frequent night waking and lack of co-sleeping. Further studies are required on a larger sample size to confirm and generalize the results that have been obtained. Contributions SMCL: Data collection and analysis; BB: Study protocol and data analysis; PM: Data collection; AK: Final correction and data collection. BB will act as guarantor for this paper. Conflict of Interest None. Source of Funding None.
References 1. Oswald I. Sleep as restorative process: human clues. Prog Brain Res. 1980;53:279–88. 2. Anders TF, Eiben LA. Pediatric sleep disorders: a review of the past 10 years. J Am Acad Child Adolesc Psychiatry. 1997;36:9–20. 3. Morgenthaler TI, Owens J, Alessi C, et al. Practice parameters for behavioral treatment of bedtime problems and night wakings in infants and young children. Sleep. 2006;29:1277–81. 4. Mindell JA, Du Mond CE, Sadeh A, Telofski LS, Kulkarni N, Gunn E. Efficacy of an internet-based intervention for infant and toddler sleep disturbances. Sleep. 2011;34:451–8. 5. Mindell JA, Sadeh A, Wiegand B, How TH, Goh DY. Cross-cultural differences in infant and toddler sleep. Sleep Med. 2010;11:274–80. 6. Kohyama J, Mindell JA, Sadeh A. Sleep characteristics of young children in Japan: internet study and comparison with other Asian countries. Pediatr Int. 2011;53:649–55. 7. Fazzi E, Zaccagnino M, Capsoni C, et al. A questionnaire on sleep behaviour in the first years of life: preliminary results from a normative sample. Funct Neurol. 2006;21:151–8.
8. Iglowstein I, Jenni OG, Molinari L, Largo RH. Sleep duration from infancy to adolescence: reference values and generational trends. Pediatrics. 2003;111:302–7. 9. Bamford FN, Bannister RP, Benjamin CM, Hillier VF, Ward BS, Moore WM. Sleep in the first year of life. Dev Med Child Neurol. 1990;32:718–24. 10. Sadeh A, Mindell JA, Luedtke K, Wiegand B. Sleep and sleep ecology in the first 3 years: a web-based study. J Sleep Res. 2009;18:60– 73. 11. Ward TM, Gay C, Anders TF, Alkon A, Lee KA. Sleep and napping patterns in 3-to-5-year old children attending full-day childcare centers. J Pediatr Psychol. 2008;33:666–72. 12. Weissbluth M. Naps in children: 6 months-7 years. Sleep. 1995;18: 82–7. 13. Latz S, Wolf AW, Lozoff B. Cosleeping in context: sleep practices and problems in young children in Japan and the United States. Arch Pediatr Adolesc Med. 1999;153:339–46. 14. Yang CK, Hahn HM. Cosleeping in young Korean children. J Dev Behav Pediatr. 2002;23:151–7. 15. Mindell JA, Sadeh A, Kohyama J, How TH. Parental behaviors and sleep outcomes in infants and toddlers: a cross-cultural comparison. Sleep Med. 2010;11:393–9. 16. Adair R, Bauchner H, Philipp B, Levenson S, Zuckerman B. Night waking during infancy: role of parental presence at bedtime. Pediatrics. 1991;87:500–4. 17. Scott G, Richards MP. Night waking in 1-year-old children in England. Child Care Health Dev. 1990;16:283–302. 18. Anders TF, Halpern LF, Hua J. Sleeping through the night: a developmental perspective. Pediatrics. 1992;90:554–60. 19. Gaylor EE, Goodlin-Jones BL, Anders TF. Classification of young children’s sleep problems: a pilot study. J Am Acad Child Adolesc Psychiatry. 2001;40:61–7. 20. Ottaviano S, Giannotti F, Cortesi F, Bruni O, Ottaviano C. Sleep characteristics in healthy children from birth to 6 years of age in the urban area of Rome. Sleep. 1996;19:1–3. 21. Morrell JM. The role of maternal cognitions in infant sleep problems as assessed by a new instrument, the maternal cognitions about infant sleep questionnaire. J Child Psychol Psychiatry. 1999;40:247–58. 22. Goodlin-Jones BL, Burnham MM, Gaylor EE, Anders TF. Night waking, sleep-wake organization, and self-soothing in the first year of life. J Dev Behav Pediatr. 2001;22:226–33. 23. Bharti B, Mehta A, Malhi P. Sleep problems in children: a guide for primary care physicians. Indian J Pediatr. 2013;80:492–8. 24. Bharti B, Malhi P, Kashyap S. Patterns and problems of sleep in school going children. Indian Pediatr. 2006;43:35–8. 25. Jenni OG, O’Connor BB. Children’s sleep: an interplay between culture and biology. Pediatrics. 2005;115:S204–16. 26. Baldi I, Gulati A, Lorenzoni G, et al. Public health implications of obstructive sleep apnea burden. Indian J Pediatr. 2014;81:S55–62. 27. Ravikiran SR, Kumar PM, Latha KS. Sleep problems in preschool and school aged rural Indian children. Indian Pediatr. 2011;48:221–3. 28. Bayer JK, Hiscock H, Hampton A, Wake M. Sleep problems in young infants and maternal mental and physical health. J Paediatr Child Health. 2007;43:66–73.
