The role of sleep in happy, healthy baby development

16 November 2018

First published June 2016

Why is sleep so important for a baby's development? 

The importance of sleep in baby development

It has been estimated that between 20-30% of children experience sleep problems during the first three years of life (Sadeh et al, 2011). For parents, this poses a major concern as poor sleep, in turn, disrupts their sleep and adversely affects their mood (Hiscock et al, 2001). Unsurprisingly, sleep issues are a key factor driving parents to seek healthcare professional advice in early childhood (Sadeh et al, 2011, El-Sheikh et al, 2015).

Providing advice to parents on how to improve their baby's sleep has significant advantages beyond merely reducing sleep disturbance for parent and baby, as sleep plays a major role in their child's cognitive, social, emotional and behavioural development (Curcio et al, 2006; Spruyt et al, 2008; Dang-Vu et al, 2005; Stickgold et al, 2005; Friedrich et al, 2015; Seehagen et al, 2015; Dionne et al, 2011).

However, there is wide variation in how children are put to bed (Mindell et al 2010), and in how parents interpret whether their child has a sleep problem or not (Sadeh et al, 2011). It is critical, therefore, that parents receive evidence-based advice to help their child get the best possible sleep; and therefore the best start in life.

 

Identifying sleep problems

Although infants and young children spend the majority of their time asleep (El-Sheikh et al, 2015), there is significant variability in sleep patterns (Thiedke et al, 2001). As such, determining whether a baby has a sleep problem is often dependent upon parental perception and tolerance (Thiedke et al, 2001). In a global study of the parents of over 29,000 infants and toddlers aged under three years, it was found that there are profound differences between countries regarding the time that baby is put to bed, their sleeping arrangements (whether in a cot or parental bed*) and if the baby sleeps alone or with someone else in the bedroom. In addition, there is significant individual variation among babies in the time they fall asleep, the duration of sleep and the factors that can disrupt their sleeping (Mindell et al 2010). With the diverse range of sleeping patterns used by parents, it is important to identify children's sleeping arrangements and take these into account when giving advice.

 

Why sleep problems occur

Sleep patterns differ depending on the infant's developmental stage (Thiedke et al, 2001). Repeated night-time wakening is considered normal in a two-month old, but abnormal in a two-year old (Thiedke et al, 2001). It is to be expected that 100% of newborns will wake up in the night, dropping to 20-30% of six-month olds (Thiedke et al, 2001).

The majority of sleep disturbances in children are secondary, where the disruption is transient. The most common include difficulty in falling asleep/bedtime resistance and night wakening (Thiedke et al, 2001; Mindell et al, 2010). There are also primary causes of sleep disturbance (see Box 1).


Box 1: Primary sleep disorders

Common primary sleep disorders in children include:

  • Parasomnias - A general term for abnormal sleep that can include movement, behaviours, emotions and dreams
  • Night terrors - Usually occur in children aged 3-8 years around 90 minutes into sleep
  • Somnambulism (sleepwalking) and somniloquy (sleeptalking) - Usually occur in school-age children and is more prevalent in boys
  • Nocturnal enuresis (bedwetting) - Can be categorised as a parasomnia, in some children this is caused by the bladder of sufferers holding smaller volumes of fluid before needing to be emptied, compared with unaffected children
  • Obstructive sleep apnoea - Symptoms include snoring and difficulty breathing during sleep; it affects up to 3% of children. (Thiedke et al, 2001)

 

* NICE guidelines highlight the importance of discussing the risk of sudden death syndrome associated with co-sleeping (parents or carers sleeping on a bed with an infant) (NICE guidelines CG37, 2006).


 

Box 2: How do babies sleep?

Newborn babies have a different sleep pattern to adults. One sleep cycle is approximately 45-60 minutes compared to adults whose sleep cycle is approximately 90 minutes. (ISIS, 2016) Whereas adults start with light sleep, babies enter sleep through an initial active REM stage instead (Thiedke et al, 2001). Infants spend a greater amount of time in deep sleep in comparison to adults who spend 20-25% of sleep in REM and 75-80% in Quiet Sleep (ISIS, 2016). This allows more time for brains to develop. (ISIS, 2016)


 

Infant sleep cycles differ markedly from that of adults as the sleep-wake cycle is regulated by light and dark and these rhythms take time to develop, resulting in the erratic sleep patterns of newborns (Sheldon et al, 2014).

  • Newborns divide their sleep equally between night and day, but gradually daytime sleep diminishes over the first three years oflife (Thiedke et al, 2001)
  • By around six weeks, rhythmic sleep patterns start to develop and by three­to-six months these form a regular circadian sleep-wake cycle (Sheldon et al, 2014)

 


Box 3: Benefits of sleep on baby development

  • Sleep has been shown to aid:
  • Cognitive development
  • Brain maturation, learning and memory (Dang-Vu et al, 2006)
  • Memory creation and retention (Stickgold et al, 2005; Friedrich et al, 2015; Seehagen et al, 2015)
  • Language learning (Dionne et al, 2011)
  • Data shows that babies continue to learn and adapt to stimuli even when asleep (Fifer et al, 2010)
  • Emotional and behavioural development
  • Behaviour and temperament; babies who sleep more have been shown to be more approachable and adaptable (Spruyt et al, 2008)

The nature of infant sleep also differs markedly from that of adults (Thiedke et al, 2001). Everyone experiences sleep cycles that alternate between Rapid Eye Movement (REM) sleep, where the brain is active as it processes information and dreaming occurs, and a resting phase, known as Non Rapid Eye Movement (NREM) or Quiet Sleep (ISIS, 2016; Sheldon et al, 2014), where tissue growth and repair occurs and growth and development hormones are released. The proportion of REM sleep is highest in infancy and declines to less than 25% by the age of 5, meaning that infants have much shorter sleep cycles than adults. (Thiedke et al, 2001; Sheldon et al, 2014).

 

Why sleep is essential to baby’s development

A baby creates up to 1.8 million new synaptic connections in the brain per second, and what a baby feels, sees, hears and smells determines which of these connections survive (Eliot et al, 1999).

Given that infants spend the majority of their time asleep, and that a significant proportion of sleep is in the processing REM stage (Thiedke et al, 2001), this suggests that sleep is essential for baby's brain and body development (El-Sheikh et al, 2015; Dang-Vu et al, 2006).

Certainly during this period, the brain is at its most plastic, grows fastest and is most responsive to external stimuli (WHO, 2014). Most of the brain's neural pathways supporting communication, understanding, social development and emotional well being grow rapidly in the first three years oflife (WHO, 2014).

The benefits of sleep, however, are not just seen in infant brain development, there is also a short-term impact on the family unit. Mothers of babies with disrupted sleep will also experience sleep disturbance, with a subsequent negative effect on mood (Hiscock et al, 2001). Improving baby's sleep has a documented improvement in maternal mood (Mindell et al, 2009).

 

The importance of bedtime routines in aiding sleep

When advising parents on how to minimise sleep problems with their baby, it is important to recognise that their perceptions can play an important role (Sadeh et al, 2011). For example, 100% of newborns will wake in the night, but it is still normal for this to occur in up to 30% of six-month olds (Thiedke et al, 2001). Cultural considerations also come to the fore: children from predominantly Asian countries often have significantly later bedtimes, shorter sleep times and increased parental perception of sleep issues (Mindell et al, 2010).

When providing advice to parents, individual factors of how they put their child to sleep and in what environment need not be considered. Data shows that advising them to adopt a consistent bedtime routine significantly improves baby's sleep (Staples et al, 2015; Mindell et al, 2009).

Implementing a bedtime routine means babies can associate this with the onset of sleep. Not only does this help with bedtime resistance, but the baby who is put to bed awake and falls asleep : naturally is also able to do this when iwaking during the night, thus avoiding parental wakening (Thiedke et al, 2001).

There are further development benefits in implementing a routine as these contribute towards infant learning, with repetition strengthening the connectivity pathways within the brain (Schiller et al, 2010). Routines also help minimise stress for babies, improve day time behaviour and aid parental sense of competence (Fiese et al, 2002).

 

The benefits of a multisensory bedtime routine

Multisensory stimulation, the concurrent stimulation of touch, smell, auditory, and/or visual stimuli, enhances the brain's processes for learning more than stimulation of a single sense (Shams et al, 2008; Sullivan et al, 1991). With 85% of a baby's brain developed by the age of three, experiences such as a multisensory bedtime routine that can enhance this process are vital (Bruner et al, 2004; WHO 2014).


Box 4: Key reasons for parents to adopt a bedtime routine

  • Helps brain development, reduces infant stress and improves day time behaviours
  • Bedtime routines help babies differentiate between sleeping and waking times, supporting their ability to self-regulate their sleep and develop a natural sleep/ wake cycle
  • Behavioural interventions for sleep problems are highly effective when used in both babies and toddlers, and in a review of 52 treatment studies, 80% of children showed a clinically significant improvement in their sleep.

 

(Curcio et al, 2006; Spruyt et al, 2008; Dang-Vu et al, 2005; Stickgold et al, 2005; Friedrich et al, 2015; Seehagen et al, 2015; Dionne et al, 2011, Fiese et al, 2002; Staples et al, 2015; Morgenthaler et al, 2006, Mindell et al, 2009)


Providing infants with consistent multisensory experiences also correlates directly with developmental benefits, such as (White-Traut et al, 2009; White­Traut et al, 2002; Hernandez-Reif et al, 2007; Mindell et al, 2009):

  • Stress reduction
  • Increased alertness
  • Improved sleep quality and duration
  • Faster progression to complete bottle feeding via a teat and reduced hospitalisation time in preterm infants

 

How to create a multisensory bedtime routine

A multisensory bedtime routine consists of various activities designed to stimulate all the senses, which are followed in the same order on a nightly basis before sleep. The younger a routine is initiated, the better (Mindell et al, 2015).

Advise parents to begin the bedtime routine with a warm bath, followed by a massage, then some quiet time, such as reading a book or singing a lullaby (Mindell et al, 2009). Used together, these provide complete multisensory stimulation through:

  • Tactile stimulation via skin-to-skin contact in the bath and during massage
  • Visual stimulation by engaging in direct eye contact
  • Auditory stimulation via the parent's voice talking during bath and massage and during quiet time
  • Olfactory stimulation through the use of baby-skin appropriate scented bath and massage products.

However, there may be a need to encourage and educate on the importance of all three elements of the bedtime routine. Market research found that, while more than 90% of UK parents (n=500) believe bath time is more than getting their child clean – it is valued time with their child and an opportunity to stimulate their developing senses, there can be a lack of multisensory stimulation (J&J, 2015). Although 93% of parents see bath time as a good opportunity to stimulate their child's senses, some senses may be overlooked – such as smell, which can limit their child's olfactory stimulation. In addition just 13% are aware of the brain development benefits of massaging their baby (J&J, 2015). Despite this, there is scope for improving education, with more than nine out of 10 parents making a concerted effort to stimulate their child's senses to help with brain development and eager to learn about new ways in which they can do so (J&J, 2015).

Data shows that combining all three elements of a multisensory bedtime routine (bath, massage and quiet time) and performing these consistently, is clinically proven to increase the quantity and duration of baby's sleep (Mindell et al, 2009).

 

 

Creating a bedtime routine

Babies are comforted by routines and familiarity. Research has shown routine touch and massage improves sleep quality and duration. There are some practical considerations that should be recommended to parents for every stage of the routine:

Bath time

  • Washing infants in a bath is generally superior to sponge bathing as it provides more tactical stimulation, helps prevent temperature loss and is a calming, soothing experience for the infant (Blume-Peytavi et al, 2009; Blume-Peytavi et al, 2011; Bryanton et al, 2004)
  • Advise parents to use a mild cleansing bar or liquid cleanser that causes minimal disruption to the pH of their baby's skin and that does not irritate the skin or eyes (AWHONN 2013). In general, liquid cleansers often contain emollients so are preferable to cleansing bars, but parents should choose products with a sufficient quantity of baby-suitable preservatives. Antibacterial soaps should be avoided where possible (AWHONN, 2013) because of the harshness of the soap and the potential negative effect it may have on normal skin colonisation
  • Use of a lavender-scented bath time product has been shown to lower baby's stress levels and crying and promote sleep and visual engagement with the parent (Field et al, 2008).

Massage

  • Massaging with oil or lotion has greater soothing effects than massage alone; with one study in healthy newborns showing massaging with oil resulted in less stress for babies (Field et al, 1996)
  • Although parents may believe olive oil is suitable for massage, data shows that direct skin application can damage the skin barrier in adults, causing redness (Rawlings et al, 2012; Danby et al, 2013; Tanojo et al, 1999). In contrast, pharmaceutical-grade mineral oil has been shown to be efficacious and non­toxic (Rawlings et al, 2012).

Quiet time

  • These include reading a book together, lullabies and cuddling, and should be the final step in the routine. Aim to have lights out within 30 minutes after the end of the bath (Mindell et al, 2009).

 

A three-week study of 405 mothers and their infants or toddlers aged 7-36 months, found that a consistent bedtime routine had a positive impact on sleep within one week, with infants on average (Mindell et al, 2009): 

  • Falling asleep 37% faster
  • Having 38% fewer night wakenings
  • Sleeping longer
  • Spending 32% less time awake

In addition, mothers reported reduced tension, depression, anger and fatigue and felt more confident in their ability to manage their child's sleep (Mindell et al, 2009).

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