REVIEW

Translating research-based knowledge about infant sleep into practice Wendy Middlemiss, PhD (Associate Professor)1 , Robin Yaure, PhD (Senior Instructor)2 , & Erron L. Huey, PhD (Assistant Professor)3 1

University of North Texas, Denton, Texas The Pennsylvania State University, Mont Alto, Pennsylvania 3 Texas Woman’s University, Denton, Texas 2

Keywords Infants, maternal; evidence-based practice; family practice; review; sleep hygiene; beliefs. Correspondence Wendy Middlemiss, PhD, Department of Educational Psychology, 1155 Union Circle, #311335, Denton, TX 76203. Tel: 940-369-8652; Fax: 940-565-2185; E-mail: [email protected] Received: 3 June 2013; accepted: 14 October 2013 doi: 10.1002/2327-6924.12159

Abstract Purpose: Review infant sleep research with a focus on understanding the elements related to infant safety and infant and maternal well-being during nighttime care. Data sources: This review summarizes current research and addresses the controversies and conflicting outcomes reported in infant nighttime care. This review addresses current literature on infant sleep patterns, as well as factors that influence infant sleep and are consequences of different care routines. Conversation points are provided to help nurse practitioners (NPs) address safety and practice concerns. Conclusions: Shared information can help parents provide a safe and healthy environment for infants and help to facilitate communication ties between the healthcare providers and the families. Implications for practice: NPs need to help parents understand infant sleep patterns norms, what is current knowledge about infant nightwakings and parental presence, as well as about approaches to altering infant sleep patterns. Integrating this knowledge with parent preferences that are influenced by cultural practices and individual differences is crucial in helping parents develop a strong sense of competence and comfort with their choices and behaviors.

Both first-time and experienced parents are concerned about infants’ sleep and the best way to deal with nighttime care (Connell-Carrick, 2006; Mindell, Telofski, Wiegand, & Kurtz, 2009). This is evidenced in the frequency with which parents raise concerns about nightwakings and ask for help in dealing with infants’ nighttime care during well-care visits (Boyle & Cropley, 2004). This places many nurse practitioners (NPs) in the position of providing information about safe and healthy sleep practices and nighttime care (Krouse et al., 2012; Sobralske & Gruber, 2009). In helping parents with issues around infant sleep, NPs must often sort through conflicting research and best practice policies. This article helps provide a foundation for effective discussions of nighttime care by highlighting relevant infant sleep research and providing conversation points for addressing parent questions (See Table 1.). Four common areas of concern for parents and practitioners include (1) what are “normal” infant sleep and waking patterns? (2)  C 2014 American Association of Nurse Practitioners

Are nightwakings a problem? (3) Is it okay to stay with infants when they fall asleep? (4) Is sleep training safe and healthy for infants? We will take each of these questions in turn, identifying relevant recent research and then providing suggested conversation points in regard to them. In a final summary, we will address the question of how NPs help parents integrate their preferences for care and best practice information. Table 1 provides definitions and key concepts that will be used throughout this discussion.

What are “normal” infant sleep and waking patterns? Important in childrearing is to understand patterns of development—this is particularly important when dealing with infant sleep. In this section, normative patterns of sleep are reviewed with a focus on how sharing this information with parents can support parents in early care. 1

Translating infant sleep research into practice

Table 1 Key concepts Co-parenting—Quality of parents’ ability to work together regarding infant needs. Emotional availability—Openness of parent to provide emotional signs to their infants and respond to signals from infant. Infant signaling—Often defined by crying in relation to infant sleep are behaviors that indicate infants’ needs and indicate to others that needs are present. Insecure-avoidant attachment—Type of attachment or relationship indicating the child’s lack of trust in parent or caregiver’s likelihood to be responsive. Maternal sensitivity—Mothers’ recognition of and responding to infant signals and needs. Modified intervention approach—Use of behavioral conditioning approaches to remove the reward for a behavior and through that lack of reward extinguish that behavior. Often describing sleep training methods that require gradually decreasing response to infant signals/crying at transition to sleep or at waking with the goal of extinguishing the signals/crying. Normative sleep patterns—Sleep patterns that are considered to be average/expected based on age of infant. Parental adaptation—Parents’ abilities to, and comfort with, adjusting their responses to meet the demands of their infants’ behaviors and needs. Secure attachment—Relationship child has to parent that involves trust and expectations of responsiveness. Self-regulation—Ability to physiologically manage own emotional and behavioral activities. Self-settling—Ability to transition to sleep and to wake and return to sleep without parental assistance. Sleep hygiene—Healthy sleep patterns as reflected in number of nightwakings and latency to sleep. Sleep training/sleep interventions—Planned activities geared toward increasing sleep time and reducing infants’ signaling upon waking. Synchronous responding—Parental response to infant signal with a match between infants’ need and response. Unmodified behavioral extinction—Use of behavioral conditioning approaches to remove the reward for a behavior and through that lack of reward extinguish that bahavior. Often refers to sleep training methods that require that no response to infant signals/crying at transition to sleep or at waking with the goal of extinguishing the signals/crying.

Current research Many parents are unaware of the fluctuations that are normal aspects of infants’ sleep. As an overall pattern, parents may anticipate that infants will begin to wake less frequently by 6 months of age. However, the majority of infants will continue to experience waking through the first 36 months of life (Weinraub et al., 2012). In addition to this overall pattern of sleep, general fluctuations in sleep can be anticipated for each infant. This was evidenced in research where 15% of infants who self-settled on one night cry for attention after waking the next (Gaylor, Goodlin-Jones, & Anders, 2001) and 81% of infants identified as signalers, that is, infants who 2

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cry upon waking, self-settle on some nights (Keener, Zeanah, & Anders, 1989). These changes in sleep patterns often result from infants’ developing circadian and ultradian rhythms and represent the maturing capacity of their physiological regulatory systems (Anders, Halpern, & Hua, 1992). Additionally, these variations in sleepwake patterns can result from changes in infant health or family setting (Burnham, Goodlin-Jones, Gaylor, & Anders, 2002). In addition to these fluctuations, changes in infants’ sleep behavior can result from physical and cognitive changes that occur in the first year. Increased mobility around 6 months of age may lead infants to again begin to wake more frequently and may lead some infants who have resettled back to sleep without parents’ assistance to require parents’ attention upon waking. Additionally, with the development of separation anxiety, infants who had been sleeping and returning to sleep upon waking without parents’ assistance may start to wake and require the comfort of a reunion before returning to sleep (Scher, 2001). By 18 months most infants, whether waking or not in previous months, will achieve longer periods of sleep without requiring parental attention to return to sleep after waking (Weinraub et al., 2012).

Conversation points Given these normative fluctuations in sleep patterns, an important foundational message to share with parents is that infants’ sleep habits may well change from night to night, as well as within the first few years. Sharing this basic information with parents is one way of assuring parents that infants’ waking does not necessarily mean that the parents are doing something wrong. Rather, many wakings occur naturally and represent changes in the infant or home environment, develop, age, or health. New and experienced parents often report concerns about infant nighttime sleep to practitioners (Weinraub et al., 2012). By helping parents understand what is considered “normal” and also understand possible causes of varying sleep patterns, NPs may be able to reduce parents’ anxiety. The importance of understanding the variability in sleep patterns and the numerous reasons sleep patterns change is evident in a program developed and implemented with mothers whose infants were identified as having difficult temperamental characteristics (Thome & Skulladottir, 2005). In this work, nurses engaged mothers in an educational intervention that helped them understand that their infants’ temperamental characteristics were likely to contribute to nightwakings. By sharing information about the increased likelihood that infants with these characteristics may wake at night or have difficulty settling, nurses helped mothers understand that

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infants’ waking was not necessarily associated with any specific parent behavior or choice of nighttime care. The sharing of this information was associated with significant improvement in mothers’ mental well-being.

Are nightwakings a problem? Nightwakings, although shown to be part of normal infant patterns, are often defined as problematic or even “disordered” (Blunden, Thompson, & Dawson, 2011; Loutzenhiser, Ahlquist, & Hoffman, 2011; Morgenthaler et al., 2006; Richman, 1981; St. James-Roberts, 2012). Thus, much of the current research and best practice literature on infant sleep centers on the nature of nightwakings and how to reduce or eliminate them. In this section, we examine research related to nighttime wakings and their impact on infant well-being and nighttime care.

Current research Nighttime wakings and maternal well-being. Sadeh, Mindell, and Owens (2011) stated that nightwakings may lead to a host of problems for parents and infants, such as “parental stress, maternal depression, reduced sense of competence, poor physical health and reduced quality of life” (p. 335). In addition, McDaniel and Teti (2012) found that increased infant wakings during the first 3 months of life were associated with a decrease in co-parenting, defined as the ability of parents “to work together to raise the child” (McDaniel & Teti, 2012, p. 886). Concern has been raised also about how infant nightwakings may affect maternal well-being, especially levels of maternal depression (Bayer, Hiscock, Hampton, & Wake, 2007; Goldberg et al., 2013; Karraker & Young, 2007). Nightwakings, however, may not be the strongest contributor to postnatal depression. Current research suggests important contributing factors for postnatal depression include onset of depression, (i.e., pre- or postnatal), support systems present for mothers, and maternal perception of sleep problems (Goldberg et al. 2013). Although an association between nighttime wakings and maternal depression has been clearly identified, little research has tackled the direction of this association and the nature of the relation between these two aspects of nighttime care. In exploring this question, McDaniel and Teti (2012) examined the relation between maternal depression and infant wakings in a manner that allowed the researchers to examine the direction of the relation between nightwakings and depression. As found in earlier research, infants’ nightwakings were related to increased presence of maternal depression, although this

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relationship was indirect with perceptions of co-parenting being a mediating variable. Thus, the perception of coparenting became more negative with increased nightwakings, which was associated with increased maternal depression and anxiety. Maternal anxiety increased the likelihood that mothers would check on their infants during the night and even wake them to assure they were well. This report calls into question whether it is nightwakings themselves that lead to increased depression or whether it the perception of the situation that causes more problems. Other research exploring the relation between maternal depression and infant nightwakings showed that parent presence during infants’ transition to sleep at bedtime was not the primary factor associated with wakings. It showed that depressed mothers were more likely to intervene with their infants upon awakening (Teti & Crosby, 2012). This intervening was considered to be the primary cause of increased nightwakings of the infants in subsequent nights. Thus, it may be that not all parents who are present at bedtime or during the night had behaviors that lead to increased nightwakings for the infants.

Nightwakings and infants’ later sleep patterns. Parents and practitioners are concerned about whether early nightwakings lead to nightwakings later in childhood (Sadeh et al., 2011). Although a seeming area of controversy, research has not found a clear link between nighttime wakings during early infancy and later sleep problems (Blunden et al., 2011; Weinraub et al., 2012). Many studies find a link between the number of nightwakings at different points in the first year of life, with infants who wake continuing to have higher levels of waking (Weinraub et al., 2012). However, at 18 months of age, the number of nightwakings becomes similar for most infants, regardless of earlier waking patterns (Sadeh, Tikotsky, & Scher, 2010; Weinraub et al., 2012).

Conversation points Without doubt, being well rested is important for both infants and their caretakers. However, messages focused on reducing nightwakings by limiting parent presence may not be well received by parents and may not be helpful in influencing nighttime sleep behavior. When too narrowly focused on problems associated with parent presence and nightwakings, these messages often lead to conversations that overlook other factors important to infants’ development. These limited conversations may also reduce parents’ understanding surrounding nightwakings and make them afraid to respond to their infant when their infant awakens and signals. NPs who share the broader scope of information about nightwakings can help parents weigh the benefits of 3

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breastfeeding and responsiveness to infant signals with concerns regarding sleep patterns and effects on parents’ well-being (Heinig & Banuelos, 2006). Since breastfeeding is important to infants’ health, as well as potentially protects infants from sudden infant death syndrome (SIDS) events (McKenna & McDade, 2005), incorporating this information into the discussion may increase the likelihood that parents accept this sleep pattern rather than consider wakings as signs of problematic sleep. Additionally, parents who are more comfortable with the choices they make regarding nighttime care feel less distress and more competent as parents (Yaure, Middlemiss, & Huey, 2011).

Is it okay to stay with infants when they fall asleep? Much of the recent research on nightwakings has centered on parent presence at bedtime and how this may lead to increased nightwakings (Blunden et al., 2011; ˇ cec, 2012; Meijer, 2011; Morgenthaler Matthey & Crnˇ et al., 2006). Despite this research and the likelihood of infants waking in parents presence during transitions to sleep, the majority of parents reported a clear preference for remaining present during infants’ transition to sleep. In this section, we examine the research regarding parent presence and quality of infant sleep.

Current research While some research has identified more infant nightwakings when parents remain present during transitions to sleep (St. James-Roberts, 2007), other studies have found nightwaking to be similar for solitary sleeping and bed-sharing infants (Baddock, Galland, Bolton, Williams, & Taylor, 2006). Additionally, infant intrinsic factors, such as behavioral dysregulation and separation stress, have been shown to be associated with higher levels of nightwakings (DeLeon & Karraker, 2007), which suggests that parent presence may only be one factor related to nightwakings. Higher levels of cortisol have been associated with routines in which infants self-settle (Middlemiss et al., 2009). Other research has examined whether mother–infant attachment may play a helpful or detrimental role in quality of infant sleep. In this body of research, parent presence and secure attachment relationships have been associated with nightwakings with securely attached infants have been reported to have more nightwakings and more difficulty at bedtime, based on maternal perception of the sleep routine (Scher, 2001). In a separate study, it has been shown that infants with an insecure-avoidant attachment were reported as waking the least at age 6 months (Beijers, Jansen, Riksen-Walraven, & Weerth, 4

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2011). Although this research suggests secure attachment may be associated with increased nightwakings and insecure attachment with fewer, the researchers suggested that mothers of insecurely attached infants were less likely to perceive their infant’s wakefulness as a signal requiring a response, and thus, their infants eventually began to signal less at night because they had learned to expect no response to their signals. The contrary would be suggested regarding mothers whose infants are securely attached given the level of mutual responsiveness and synchrony in mother–infant relationships. The importance of mutual responsiveness has been supported in numerous research reports. Much of this research focuses on the role of mothers’ emotional availability, defined as the mothers’ capacity to respond to emotional signals of another infant, a crucial aspect of the attachment relationship (Biringen, 2000; Miller & Commons, 2010). This research focuses on the importance of this type of interaction as for the infants’ development of self-regulation and autonomy. For example, although research has suggested having infants self-settle is essential to infants’ progress toward selfregulation (Sadeh et al., 2010), a significant body of research has found important links between synchronous responding and self-regulation (Feldman, 2007). Further, Teti, Kim, Mayer, and Countermine (2010) found that mothers’ emotional availability at bedtime was related to fewer infant nightwakings and fewer times mothers had to return to their infants at bedtime. Finally, mothers’ emotional availability was inversely related to their perceptions of whether their infants had a sleep difficulty.

Number of nightwakings versus time awake. Although infants whose parents remained present during transitions to sleep were more likely to wake, many studies showed that infants attended to upon waking or whose routines included bed-sharing woke for shorter periods of time than infants engaged in selfsettling sleep (Mao, Burnham, Goodlin-Jones, Gaylor, & Anders, 2004). In a longitudinal study of children from 12 months to 4 years of age (Bordeleau, Bernier, & Carrier, 2012a, 2012b), the quality of early caregiving was related to sleep regulation during later childhood. Specifically they showed that “maternal sensitivity, maternal mind-mindedness [mothers’ comments on another’s emotions], maternal autonomy support, and the quality of father-child interactions in infancy were all significantly and positively associated with children’s percentage of nighttime sleep at preschool age” (p. 6). Maternal sensitivity was also reported as important in supporting infant sleep, even in infants identified as having nightwakings (Priddis, 2009). Nightwakings and breastfeeding. Breastfeeding is associated with different sleep patterns than those

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anticipated with bottle-fed babies (St. James-Roberts, 2007). Consequently, a focus on reducing nightwakings can compromise discussion of breastfeeding, as well as mothers’ likelihood to continue to engage in breastfeeding during the first year. With this, NPs are in a position of needing to help parents weigh the benefits of breastfeeding with the associated patterns of sleep. One important conversation point in these discussions may be the benefits associated with breastfeeding. Well-known benefits include the positive impact on infants’ developing brains and immune systems (Herba et al., 2013), as well as infants’ social–emotional well-being (Kim et al., 2011). In regard to sleep, the tryptophan in breast milk can aid infants’ transition to sleep (Narvaez, 2013). Further, although infants who are breastfed may wake more frequently, they have been found to return to sleep more readily (McKenna & McDade, 2005). Infants who are breastfed often sleep in close proximity to parents and may enjoy more skin-to-skin contact, both of which have been identified as increasing either infant’s safety during sleep or overall development of regulatory systems (McKenna & McDade, 2005; McKenna & Volpe, 2007). It is based, in great part, on these health benefits that the American Academy of Pediatrics has recommended mothers breastfeed at least through infants’ first year of life (American Academy of Pediatrics, 2005). Finally, breastfeeding has been identified as protecting infants against SIDS events (McKenna & McDade, 2005)—both in regard to infant–mother sleep position and mothers’ presence with infant and synchrony in breathing and lighter sleep stage (McKenna & McDade, 2005).

Conversation points Perhaps helpful to share with parents is research suggesting parent presence may not drive nightwakings in as direct a manner as previously proposed (Sadeh et al., 2010). This opens the pathway to talk to parents about other aspects of nighttime care—helping parents to choose routines that may better support their sense of efficacy as a parent and meet their infants’ needs. When conversations focus on this breadth of information and discussion, it is more likely that parents will make choices that fit their family’s childrearing preferences and their expectations regarding early care. As the section below addresses, being able to incorporate information provided is often affected by whether the information seems to fit with parents’ preferred parenting approaches.

(McDaniel & Teti, 2012). In addition to talking with parents about the normative nature of nightwakings as part of infants’ sleep, NPs need also to answer questions about nightwakings and parents’ desire to have longer periods of sleep.

Current research Support for sleep training. Given the use of nightwakings as defining infant nighttime problems (Richman, 1981; Sadeh et al., 2010) and the association between wakings and parent presence found in the literature (Sadeh et al., 2010), behaviorally based sleep training interventions are frequently forwarded as best practice for teaching infants to self-settle and thereby reduce nightwakings (Bayer et al., 2007; Morgenthaler et al., 2006). Behavioral sleep interventions are recommended as best practice to reduce parent presence during nighttime care, with presence often considered maladaptive and overly intrusive (Simard, Nielsen, Tremblay, Boivin, & Montplaisir, 2008). In general, sleep training approaches often involve bedtime activities that follow classical conditioning principles from behavioral theories (Middlemiss, 2004a; Morgenthaler et al., 2006; St. James-Roberts, 2007). Unmodified extinction is characterized by parents’ placing infants down to sleep and returning to attend to the infant only if the infant is in danger. This approach, although effective when used without deviation in nonresponse to infants’ signaling, is difficult for parents to tolerate, requires strict adherence to behavioral extinction techniques, and can be emotionally distressing for both infant and mother (Yaure et al., 2011). Given the challenges of unmodified intervention approaches, a modified approach allows parents to provide soothing for increasingly shorter periods of time—while increasing the period of time between soothing. Soothing often entails only verbal assurance or presence without contact. Modified approaches can be more palatable for parents, though challenging (Morgenthaler et al., 2006). Both approaches are identified as successful in that infants will settle to sleep without crying within a few days’ time (Middlemiss, Granger, Goldberg, & Nathans, 2012). Effects of sleep training. Given the controversies in the research regarding sleep training, it is important to examine both the proposed benefits and risks.

Is sleep training safe and healthy for infants?

Proposed benefits

Nightwakings may be difficult, even when parents understand that waking is part of normal sleep patterns

Recommendations for the use of behavioral approaches to reduce infant nightwakings and signaling 5

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for assistance in returning to sleep are generally based on the premise that the problems associated with perceived infant and child sleep problems are worse than the temporary discomforts both parents and children experience during the sleep training phase (Sadeh et al., 2011). Sadeh and colleagues noted that sleep training programs are intended to assist infants and children to learn to selfsoothe, rather than “give up” (p. 336) trying to signal their distress.

Possible risks The contention that the benefits of sleep training programs outweigh the presumed short period of distress is actively and intensely debated (Miller & Commons, 2010; Middlemiss et al., 2012, 2013; Narvaez, 2012; Price, Hiscock, & Gradisar, 2013; Price, Wake, Ukoumunne, & Hiscock, 2012). Concern has been raised regarding whether interventions harm infants’ socioemotional well-being or the emotional bond between mother–infant (Ball & Volpe, 2013; Blunden et al., 2011; Miller & Commons, 2010), or parents’ sense of efficacy or adaptation to care (Countermine & Teti, 2010; Middlemiss, Goldberg, Granger, & Nievar, 2009), or create care environments contrary to those that support healthy development (Blunden et al., 2011). Impact on infants. For example, it has been proposed that not responding to an infant’s cries at night or being inconsistent in responding between day and night signals for care may lead to increased infant stress (Porter, 2007), with maternal responsiveness necessary to help infants self-regulate their physical and emotional responses to stress. Exploration extends to both experiences during the time of the sleep intervention (Middlemiss et al., 2012) and on later child outcomes (Hiscock, Bayer, Hampton, Ukoumunne, & Wake, 2008; Priddis, 2009). Behavioral sleep intervention has been shown to be associated with continued high levels of stress during the time of the behavioral sleep intervention (Middlemiss et al., 2012). In this research, infants were found to have high levels of stress, as measured by cortisol, both at the beginning of the behavioral intervention when they cry during their transition to sleep. Cortisol levels remain high even after infants have stopped crying at their transition to sleep. In a separate study, an increase in autonomic system arousal was reported for neonates during episodes of maternal separation (Morgan, Horn, & Bergman, 2011). Further, research has shown the importance of responsiveness and presence in that infants who co-slept with a parent and had maternal responsiveness throughout the night were found to have a lower stress reaction measured by cortisol level to a mildly stressful event 6

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(Tollenaar, Beijers, Jansen, Riksen-Walraven, & de Weerth, 2012). The researchers suggested that the infant who received more attention at night may have more external emotional regulation assistance than those who sleep alone at night and do not receive as much nocturnal attention. At present, no research has been reported to examine objective stress levels directly following use of a sleep training intervention (Narvaez, 2012), although some studies have tried to assess the benefits and harm associated with sleep training programs. Hiscock et al. (2008), for example, reported no negative or positive effects associated with markers of children’s socioemotional outcomes in comparison to infants who had not been engaged in the identified sleep training program. Other researchers have examined sleep training outcomes within a short postintervention period. These researchers have suggested the value of sleep interventions because of their association with longer periods of sleep for infants and more rest for parents. For example, in their research, Crnˇcec, Matthey, and Nemeth (2010) have reported that sleep training does not cause undue stress for infants, with infant mental health not demonstratively negatively affected by sleep training. These researchers argued that infant sleep problems were risk factor for problems experienced by the infant and its family; and, thus, that it was more important that to overcome sleep problems to avoid long-term family and child behavioral problems and they put the burden of proof for problems on other researchers examining this relationship. Impact on parents. In questioning whether sleep training is harmful to parents, research indicates that mothers who do not respond to their infants’ needs, including sleep-related demands, report higher emotional dis¨ tress (Ostberg, Hagekull, & Hagelin,2007; Sadeh, FlintOfir, Tirosh, & Tikotzky, 2007). Maternal nonresponsiveness during nighttime routines has been related to mothers’ experiences of stress, indicated by higher levels of cortisol, during nighttime care (Middlemiss et al., 2009; Yaure, et al., 2011). Further, maternal selfreported stress has been shown to be a relatively stable individual characteristic over time and predictive ¨ of higher maternal stress 7 years later (Ostberg et al., 2007). Parents appear to be more comfortable being present during infants’ transition to sleep in contrast to employing behavioral extinction approaches of self-settling routines (Morgenthaler et al., 2006; St. James-Roberts, 2007). Echoing these concerns regarding nonresponse to infants during nighttime care is research noting that an infant’s cries at night are a necessary part of the infant’s communicative repertoire (Blunden et al., 2011). Porter

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(2007) supports that responding to infant cries at night lays the foundation for emotional self-regulation and a sounder interpersonal relationship between the parent and child. The intensity of the debate and uncertainty of the safety of behavioral sleep interventions is evident in parents’ efforts to understand best practice (Morgenthaler et al., 2006). Parents are often concerned about whether ignoring infant signals or delaying response to these signals will harm the attachment relationship between the parent and child, which is built upon the infant’s expectation of parental responses (Middlemiss, 2013; Narvaez, 2013; Yaure et al., 2011).

Conversation points Given the debate in the literature, the benefits of responding to infants’ distress, and the necessity for restful sleep, discussions about sleep interventions may be best focused on approaches that do not require periods of nonresponsiveness to infant crying (Blunden et al., 2011). If parents are interested in nighttime care approaches that may increase infants’ settling, guiding parents to approaches that do not introduce risk is critical. For example, one message may be to help parents identify interventions, such as fading or scheduled waking, that can increase infants’ self-settling without requiring nonresponsiveness to infant signaling. Compliance with sleep training approaches remains a focal concern when helping parents with their infants’ sleep routines (Hauck, Hall, Dhaliwal, Bennett, & Wells, 2011). Recommendations require nonresponsiveness to infants’ signaling, which has been reported across the literature to be potentially harmful for infants and to be uncomfortable for parents, even for parents who have chosen this practice, particularly in the presence of infants’ distress (Morgenthaler et al., 2006; Yaure et al., 2011). When parents have strong preferences for changing current nighttime patterns, it is important to guide parents toward making changes in a manner that support infants’ development and safety. The following sections address the research and general practices often used to change infant sleep patterns and present important considerations for NPs and parents.

How can NPs help parents integrate parents’ preferences for care and best practice? Researchers continue to identify the importance of parents’ viewpoints regarding care, both in regard to how well parents incorporate suggested practices in their care routines (Epstein & Jolly, 2009) and whether a recommended practice is one to which the parent can adapt

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(Epstein & Jolly, 2009; Hauck et al., 2002; Middlemiss, 2005; Moon, Oden, & Grady, 2004; Nobile & Drotar, 2003; Pickett, Luo, & Lauderdale, 2005). Disparities in infant safety, particularly in SIDS rates across both family socioeconomic levels and ethnicity, suggest clearly that how information is presented may impact the likelihood that families engage in healthy practices (Colson, Bergman, Shapiro, & Leventhal, 2001; Cowan, 2010; Volpe et al., 2013). In regard to infant nighttime care, the lack of consensus regarding what constitutes best care practice approaches can create a challenge for parents (Sobralske & Gruber, 2009; Morgenthaler et al., 2006). NPs can help parents understand what normative sleep patterns are like, to make decisions about nighttime care and to feel comfortable about their choices. Perhaps of greatest benefit is that information provided can be set within a framework salient to parents, increasing likelihood that information about development and safety can be heard and integrated into parental choices about care. Thus, sharing information with parents about the natural fluctuations in sleep, importance of responsiveness, and information about sleep training may be very helpful in supporting parents in early care. With this information, parents can gain more realistic expectations about caring for infants during sleep, have a better understanding regarding infant sleep behavior, and improve their feelings of competence and positive mental health (Hauck et al., 2011; Thome & Alder, 1999). Parent preferences may be an important key to providing helpful information about infant sleep health and safety in a manner that impacts parents’ nighttime care behavior. Whether information gathered in a laboratory setting during research or in a survey of parents’ reports, it is apparent that families engage in a diversity of care routines (Ball & Volpe, 2013; Volpe, Ball, & McKenna, 2013). Even though parents engage in a variety of nighttime care routines, they typically view infant nightwakings as problematic (Volpe et al., 2013), but they also prefer to respond to infants’ needs during infants’ transition to sleep and during nighttime wakings (Morgenthaler et al., 2006). Therefore, parents may not heed recommendations focused solely on reducing nighttime wakings or consider sleep intervention routines as appropriate to their nighttime care approaches (Volpe et al., 2013). This can affect the discussion of important infant sleep safety and socioemotional development or even discourage such discussions with parents (Huey & Middlemiss, 2012). Thus, it is important for NPs to consider the needs and beliefs of the family in addition to understanding the complexity of the research on infant nightwakings and the need for parents to be responsive to their infants’ needs and to feel competent as parents. 7

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Research, as noted herein, also clearly supports parents’ preferences for remaining present and being responsive to infants during nighttime care (Sadeh et al., 2011). However, because responsivity and presence during nighttime care are associated with the potential for infant waking and signaling, use of responsive nighttime care routines are often discouraged. This creates a challenge for NPs to find the balance between recommendations for nighttime care that are likely to decrease infant nightwakings and those that may include or support parents’ presence during nighttime care.

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to parents’ pleasure with caretaking, opportunities for parental personal time, and parents’ irritability with their child’s sleep and related amounts of parent sleep (Hagekull & Bohlin, 1990). In regard to infant nighttime care and adaptation to the chosen routine, research has shown higher levels of parental stress to be related to lower parental self-efficacy (Jones & Prinz, 2005). Parents who engage in care practices that meet infants’ developing needs and fit their families’ goals and acknowledge common infant sleep patterns may gain more readily a sense of competence in their role as parents (Salonen et al., 2010).

A path for families and practitioners Researchers are beginning to find a path through this seeming jumble of information—a path that is marked both by findings that presence supports infant sleep and a sense of parental efficacy regarding their choices for care. The importance of both parent presence and responsiveness is evident in research demonstrating that when the parents were responsive to infants’ needs, parental adaptation was predictive of children’s higher functioning and adjustment levels over time (Countermine & Teti, 2010). These parent–child interactions are key factors in the development of the attachment relationship between the infant and mother, according to attachment theory (Bretherton, 1992). If a mother responds in an appropriate and consistent manner to her infant’s cries, their attachment relationship is expected to be more secure than if the mother does not respond appropriately or consistently. In this framework, parental adaptation is conceptually based on indices that tap into parents’ satisfaction with their care outcomes, perception of the efficacy of their choices, and their personal distress. Adaptation is often defined as parents’ comfort with their role as the parent and has been found to be associated with the quality of parent–child interactions (Countermine & Teti, 2010). Sinai and Tikotzky (2012) found that mothers’ stress levels were associated with their “perceptions regarding the quality of their infants’ sleep” (p. 184), with those who perceived more problems with their infant’s sleep experiencing more stress. The issue may be, therefore, more about whether parents think their infants are having problems than a more objective measure of sleep problems (Middlemiss, 2004b). Parents’ preference for selfsettling routines and parents’ reticence to leave infants crying have resulted in an unnecessary proliferation of approaches that help parents teach infants to self-settle without prolonged periods of nonresponsiveness to infants’ crying (St. James-Roberts, 2007). In addition to being associated with quality of parent– child interactions, parental adaptation has been linked 8

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